Gravity Forms Retailer Test

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Type of Business/Organization*

2 Location Information

Name of Business/Organization Requesting Service*

Pickup Location Business Name

If different than organization requesting service.

Pickup Street Address*

Address Line 2

City*

County*

State*

Zip Code*

3 Contact Information

Primary Contact Name*

First Last

Primary Contact Title*

Primary Contact Email*

Primary Contact Office Phone*

Primary Contact Cell Phone*

Are you a parent organization with more than one program pickup address (e.g. a retail chain with multiple store locations)*

Parent Business/Organization Name*

Street Address*

City*

County*

State*

Zip Code*

Phone*

Are you a third party logistics provider servicing a retail location?*

Please list the retailer(s) you are servicing:*

4 Secondary Contact Information

Secondary Contact Name

First Last

Secondary Contact Title

Secondary Contact Email

Secondary Contact Office Phone

Secondary Contact Cell Phone

5 Site Logistics

Requesting entity must have the capacity to accommodate a 53-foot trailer. Can your site accommodate this?*

Provide a description of where the trailer must be dropped.*

Upload map of trailer location if available.

Max. file size: 256 MB.

Select the number of expected units per month (mattresses and box springs to be counted separately).*

Requested trailer delivery date*

Approximately how often will you need this service?*

Please note any site-specific restrictions, logistical concerns, or additional pertinent information.

6

Terms and Conditions*

I have read and agree with the terms and conditions to the Commercial Volume Pickup service requirements.

Terms & Conditions:

The Mattress Recycling Council California, LLC (“MRC”) is the non-profit mattress recycling organization certified by the State of California to plan, implement, and administer the California Mattress Recycling Program (the “Program”) established pursuant to the Used Mattress Recovery and Recycling Act (the “Act”) (California Public Resources Code § 42985, et seq.) MRC welcomes your participation in the Program on the following terms and conditions:

1. The commercial volume pick up service is open to retailers, lodging establishments, educational institutions and military bases with more than 100 units to discard. All mattresses , box-spring and futon units must have been used and discarded in California (collectively referred to as “Program Materials”). Participating mattress retailers must be registered with MRC, remit applicable fees, and remain in compliance with the Act.

2. An MRC-designated transporter will pick up Program Materials from Participant and deliver to an MRC-contracted mattress recycling facility. Transportation and recycling services are provided at MRC’s expense.

3. Participant will cooperate with the transporter to schedule convenient pickup times and to facilitate an efficient load of program materials.

4. Participant must provide at least two staff members to load Program Materials onto the trailer.

5. Participant must abide by the Commercial Volume Pickup Guidelines ("Guidelines") which outline MRC’s expectations, including but not limited to Participant:
a. keeping collected mattresses, box springs and futons dry and intact to maximize the percentage that can be recycled;
b. efficiently stacking units in the trailer to maximize capacity; and
c. completing all MRC-required paperwork and reporting requirements as outlined in the Guidelines MRC may modify the Guidelines from time to time at its discretion

6. MRC cannot accept any units that are severely damaged or soiled, twisted, wet, frozen, infested with bed-bugs or are otherwise unsuitable for recycling. Mattresses in these conditions should be disposed of as solid waste at Participant’s expense.

7. MRC-designated transporters will carry automobile liability coverage of at least $1,000,000 per occurrence. Proof of insurance will be provided to Participant upon request.

8. Participant must maintain commercial general liability insurance of at least $1,000,000 per occurrence and will provide MRC with proof of coverage upon request.

9. In no event will MRC be liable for special, indirect, consequential, or incidental damages, or lost profits, loss of revenue, or loss of use arising out of or related to these Terms & Conditions, whether such damages arise in contract, negligence, tort, under statute, in equity, at law or otherwise.

10. Participant will have control of all work and the manner in which it is performed. Nothing in these Terms & Conditions will be construed to designate Participant, or any of its employees or subcontractors, as employees, agents, joint ventures or partners of MRC.

11. MRC may terminate this agreement immediately if Participant does not meet these Terms & Conditions.

12. I have all necessary approval, capacity, and authority to enter into this Agreement on behalf of the Participant.

MRC and the Participant agree to these Terms & Conditions.

Collection Guidelines*

I have read and agree to the Commercial Volume Program Collection Guidelines on behalf of the Collection Site. Commercial Volume Program Collection Guidelines

In State Units Only*

I confirm I am not using the program to recycle mattresses and box springs discarded from any person or location outside the State of California.

Commercial General Liability Insurance*

Participant confirms commercial general liability insurance of $1,000,000 per occurrence is maintained and proof of coverage is available to MRC upon request.

7

Signature*

Print Name*

Signature Date*

THANK YOU FOR YOUR INTEREST

ATTENTION

Things to keep in mind...

CA CVP Mattress Retailer

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2

Location Information

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Contact Information

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Secondary Contact Information

5

Site Logistics

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