ReCork Reusing a Renewable Resource

First Name: Required

Last Name:

Required

Company Name:

Required

Phone Number:

Required

Email Address:

Required

Web Site: e.g.: http://www.example.com

Address Line 1:

Address Line 2:

City:

State/Province: -- Select State/Province -- Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Country: -- Select Country -- Canada United States

Zip/Postal Code:

Who are you? Please describe your business:

Which type of partner would you like to become?

Select Partner Type Public Collection Partner Recycling Partner Re-Use Partner

How many locations do you have?

If you have multiple locations, can you collect your corks in a central location?

• Yes
• No
• Not Applicable

Where is your central location?

How many corks would you expect to collect in a month?

How often would you like to send us corks?

If you are a possible re-use partner, what form of recycled cork are you interested in?

• Cork Granules
• Cork Fabric
• Cork Sheets
• Other Use