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Enter your transportation department and stores:
The transportation department for your organization is the contact person responsible for coordinating pick ups in a given area.
Associated with your transportation department will be a list of stores and zip codes. The zip codes are the areas where you are WILLING to to provide pick ups. The stores are the locations closest to those areas where a donor could drop off their items if they are too small or do not meet pick up criteria.
This form lets you submit one transportation department and ten stores. If you need to submit more transportation departments and stores, complete this form, including what you can. Then email us at signup@pickupmydonation.com, and we will send you a spreadsheet to fill out with all of your data.
Transportation Department
Please provide information about the department and designated agent responsible for scheduling donations.
Department Name*
What you call the dispatch department. (e.g. Logistics, Transportation, etc).
Contact Title*
Title of the person who manages this department (e.g. Logistics Coordinator).
Name*
First Last
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Website
Zip Codes*
Enter a comma separated lists of zip codes associated with this transportation department (e.g. 12345, 12344, 12355).
Transportation Department Stores
Please provide the store location(s) where a donor can be referred to drop off their donation in the event that it does NOT meet YOUR pick up criteria.
Store #1 Name*
Store #1 Address*
Street Address Address Line 2 City State ZIP Code
Store #1 Phone*
Store #1 Fax
Store #1 Website
Add a second store?
- Yes
Store #2
Store #2 Name*
Store #2 Address*
Street Address Address Line 2 City State ZIP Code
Store #2 Phone*
Store #2 Fax
Store #2 Website
Add a third store?
- Yes
Store #3
Store #3 Name*
Store #3 Address*
Street Address Address Line 2 City State ZIP Code
Store #3 Phone*
Store #3 Fax
Store #3 Website
Add a fourth store?
- Yes
Store #4
Store #4 Name*
Store #4 Address*
Street Address Address Line 2 City State ZIP Code
Store #4 Phone*
Store #4 Fax
Store #4 Website
Add fifth store?
- Yes
Store #5
Store #5*
Store #5 Address*
Street Address Address Line 2 City State ZIP Code
Store #5 Phone*
Store #5 Fax
Store #5 Website
Add a sixth store?
- Yes
Store #6
Store #6 Name*
Store #6 Address*
Street Address Address Line 2 City State ZIP Code
Store #6 Phone*
Store #6 Fax
Store #6 Website
Add a seventh store?
- Yes
Store #7
Store #7 Name*
Store #7 Address*
Street Address Address Line 2 City State ZIP Code
Store #7 Phone*
Store #7 Fax
Store #7 Website
Add an eighth store?
- Yes
Store #8
Store #8 Name
Store #8 Address*
Street Address Address Line 2 City State ZIP Code
Store #8 Phone*
Store #8 Fax
Store #8 Website
Add a ninth store?
- Yes
Store #9
Store #9 Name*
Store #9 Address*
Street Address Address Line 2 City State ZIP Code
Store #9 Phone*
Store #9 Fax
Store #9 Website
Add a tenth store?
- Yes
Store #10
Store #10 Name*
Store #10 Address*
Street Address Address Line 2 City State ZIP Code
Store #10 Phone*
Store #10 Fax
Store #10 Website

Name*
First Last
Organization Name*
Email*
Phone*
Payment Method*
- Pay by Credit Card
- I don't have a credit card.
Credit Card
Card Details
Cardholder Name
Bank Draft Payment Information
For pickup providers without a credit card, we offer payment via a monthly bank draft. To setup your payment, please provide your account details below:
Name on Account*
ABA Routing Number*
Account Number*
Bank Account Type*
- Checking
- Savings
- Business Checking
Name of Bank*
License Type*
- Exclusive Small Market - $99/month
- Exclusive Medium Market - $199/month
- Exclusive Key Market - $249/month
Coupon Code
Recurring Monthly Amount
$0.00

Transportation Department

Transportation Department Stores

Store #2

Store #3

Store #4

Store #5

Store #6

Store #7

Store #8

Store #9

Store #10

Bank Draft Payment Information