CassBioMed On-Demand Medical Waste Removal Please complete the form to request CheckSammy OnDemand Medical Waste Removal ServiceCustomer Support Representative Who Is Placing Order* First Last Customer Support Rep Email* Customer Support Phone Number*Pickup Location DetailsBusiness Name (company)* Purchase Order # (PO)* Contact person for Pickup* First Last Business Phone (pickup location)*Business Email (contact person)* Pickup Location* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Service Date & Time(Same day service available for orders received before 12pm EST)Requested Pickup Date* MM slash DD slash YYYY Requested Pickup Time* : HH MM AM PM AM/PM Arrival will be within 3 hours of time selectedProduct Pick-Up DetailsPharma Canisters for Pick-Up QuantityPrice:$18.00 Quantity RMW Boxes for Pick-Up QuantityPrice:$18.00 Quantity RCRA Canisters for Pick-Up QuantityPrice:$18.00 Quantity Replacement Boxes Needed QuantityPrice:$0.00 Quantity Total Pickup Fees$0.00Additional DetailsIf necessary please provide any addition details about items to be picked-up and any location specifics Photos of Items for Pick-upPlease provide photos of items to be picked up - the better the visual details of what is to be picked up - the more efficient we can be.Drop files here or Select filesAccepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 50 MB, Max. files: 15. Billing DetailsThis request, once the job is complete, will be invoiced to*Cass Information Systems IncThe ClientClient Name* Address* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Client Billing Email* Client Phone*By clicking submit, I hereby certify that I am an authorized representative for the referenced property for which I am submitting this work order (the “Property”). I have the authority to submit this work order on behalf of the Property, including but not limited to authorization to order the scope of work to be performed under the work order, and (ii) ensure payment for this work. I agree to pay all invoices in full within 30-days.
