COLLECTOR –MinnesotaDocumentation Form

Collectors: Use this form to document collection amounts of Covered Electronics Devices collected from households in Minnesota. Complete all columns in table below and sign certification. Additional instructions are on the reverse side of this form.

Collector Contact Information

Company/Entity Name
Address
Phone
E-Mail Address
Authorized Contact Person
Registered Minnesota Collector?(Y/N)

NOTE: Covered Electronic Devices (CEDs) are computers, peripherals, fax machines, DVD players, VCRs and Video Display Devices (television, laptops, and computer monitors with screen size greater than 9” diagonally) from Minnesota households

E-Scrap Collection Location (e.g., XYZ Transfer Station)

/

Date(s) Collected

/ County of Collection / Designated Recycler Name, Address / Total Weight of Household CEDs Shipped to Recycler (lbs.) / USE A NEW ROW WHERE ANY INFO IS DIFFERENT
TOTAL

Certification and Signature

The facts set forth in this form are true and complete. I certify that the total weight of Covered Electronic Devices documented on this form is fromMinnesotahousehold sources.
Name (printed)
Signature/Date

Page 1 of 2November 6, 2007

FORM INSTRUCTIONS

Contact Information

Please provide your company/organization name, address, phone number, an email address, the name of the person to contact with questions about information provided on this form, and confirm that you are on the list of registered collectors maintained by the Minnesota Pollution Control Agency found at

Material Information

In this table please provide the name of the location where the Covered Electronic Devices were collected. Also provide the date(s) the Covered Electronic Devices were collected and the MinnesotaCounty in which collection occurred. Then provide the name and address of the recycler who will recycle the Covered Electronic Devices you collected. In the last column provide the weight of the Minnesota household Covered Electronic Devices shipped to the recycler cited in the previous column.

In this table you may use a single row if the collection location, County of collection and designated recycler are the same, otherwise use multiple rows filling out each column where a different collection location, County or recycler is utilized. Provide the total amount of Covered Electronic Devices actually shipped to the recycler on the date(s) provided in each row.

Be sure to print your name, sign and date in the boxes provided in the Certification and Signature section.

Page 1 of 2November 6, 2007