Pick-Up/Delivery Request Form We will drop off two bags and a door hanger. Name: Address: Zip: (i.e. 07760) Contact Phone: (i.e. 888-555-1212) Email Address: (i.e. username@domain.com) Frequency: -- Select from the following -- 2 times per week (Monday/Thursday) 2 times per week (Tuesday/Friday) Weekly (Monday) Weekly (Tuesday) Weekly (Wednesday) Weekly (Thursday) Weekly (Friday) On request/One time Pickup/Drop Off Location: Front door Back door Other (Please specify in comments) Start Date (mm/dd): (i.e. 12/31) Comments/Questions:

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