Thank you for collecting phones for NCADV!

Name *

First

Last
Organization or Company
Shipping Address (Street Addresses only. No PO boxes.) *

Street Address

Address Line 2

City

State

Zip Code

Country
Email address: *
Please confirm: Email address: *
Phone Number

###
-
###
-
####
How did you hear about this program? *
How many cell phones are you hoping to collect and ship? *
Is this an on-going or one-time collection? *
 On-going collection 
 One-time collection 
Is this a multi-site collection?*
 Yes 
 No 
*Will this collection be held in multiple buildings/locations?

If you answered "yes" above, how many locations?

Will you need collection boxes for your efforts?* *
 No, I plan to use my own  
 Yes, please ship me boxes 
*NCADV will determine the number of boxes needed based on your estimate of how many cell phones you aim to collect, if your collection will be held in multiple locations or if it is an on-going collection. Please allow two-weeks for box delivery.
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