National Cell Phone Program Registration Form

WELCOME to the PITCH-IN CANADA's
National Cell Phone Collection Program!

The National Cell Phone Collection Program is a partnership between PITCH-IN CANADA and local community groups, schools and other civic-minded organizations. PITCH-IN CANADA's industry Partner, responsible for refurbishing and/or recycling the cell phones is PhoneBack, Canada.

The information you provide will NOT place you on other mailing lists - we do not share our mailing lists and the information will only be used by PITCH-IN CANADA. We may in the future provide you with information about new additions to our website or our programs.

A. COORDINATOR AND SCHOOL OR GROUP INFORMATION

Name of Cell Phone Collection Program Coordinator:

Position:

Name of School or Group: Please complete carefully, all of the information is required.

Mailing Address:

Town or City and Province:

Postal Code:

The E-Mail Address you specify will be used to confirm the receipt of this information.

E-Mail Address:

Phone Area Code, Number (999-9999) and Local:

Fax Area Code and Fax Number (999-9999) :

Number of People in Your School or Group

B. REIMBURSEMENT INFORMATION

To which organization should reimbursement be made:

Name of Organization, School or other fundraising cause to whom cheques should be made payable:

C. AUTHORIZATION

By selecting the "Submit Request" button below I authorize PITCH-IN CANADA to release the information provided above to PhoneBack, Canada who will send us a PITCH-IN CANADA National Cell Phone Collection Program Starter Kit. This will include a full explanation of how the program works, which items are and are not accepted under the National Cell Phone Collection Program, promotional materials and free pre-paid shipping labels enabling us to return cell phone handsets. I understand that the National Cell Phone Collection Program will also accept, but not pay for, cell phone accessories, as described in the Starter Kit. PhoneBack, Canada will recycle these accessories. I understand that PhoneBack, Canada will be responsible for sending us $1.00 for every cell phone handset collected and received by PhoneBack, Canada.

Date :

First name and surname of person submitting this request:

Name of Cell Phone Collection Program Coordinator:
Position:

Name of School or Group:		Please complete carefully, all of the information is required.
Mailing Address:

Town or City and Province:
Postal Code:
		The E-Mail Address you specify will be used to confirm the receipt of this information.
E-Mail Address:

Phone Area Code, Number (999-9999) and Local:
Fax Area Code and Fax Number (999-9999) :
Number of People in Your School or Group

Date :
First name and surname of person submitting this request: