Day of Event: -- Select -- Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Event Start Date:

Event End Date:

Event Start Time:

Start AM / PM: -- Select -- AM PM

Event End Time:

End AM / PM: -- Select -- AM PM

Name of Event:

Sponsoring Organization:

Contact's Full Name:

Event Street Address:

Village / City:

Zip Code:

Organization's E-mail Address:

Post on the Take Back Event Schedule: -- Select -- Yes No

Assist with Collection and Distribution: -- Select -- Yes No