First Name
Last Name
Title	(optional)
Company	(optional)
Address
City
State	- - - Select - - - AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY
Zip
	- - - Select - - - YES NO Is this a residential address?
Phone	xxx-xxx-xxxx
Ext
E-mail     Retype E-mail	(a valid address is required to process your request)
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	Please tell us how you heard about us - - - Select - - - Previous Experience Google Yahoo Ask Jeeves Friend or Relative Radio or Article Mailing Other If "Other" please explain

Please give us their part numbers. (separated by commas)

 

example -  HP RG5-5063-340, HP C9725A

How many fuser cores?  Qty

How many boxes are they packed in for shipping?  Qty

Comments

 

RFBC absorbs all of the costs for this program. Please be respectful of the time, effort and money it takes to process & fill your request. Make certain any questions you may have are addressed prior to submitting your request.

 

Please double check all your information, including phone and email address for accuracy. If your information is not correct we may not be able to fulfill your request.

 

                          All information submitted is for the sole purpose of the Recycle for Breast Cancer program and will not be sold or distributed to any other individuals or organizations.