City of Olathe - Household Hazardous Waste Program ELECTRONIC WASTE RECYCLING WAIVER **Please read & initial each paragraph.**

The Electronic Waste Recycling Program is operated under the Household Hazardous Waste (HHW) Program. The program provides a way for residents to recycle certain Electronic Waste items such as computers, monitors, printers, and peripherals. By completing and signing this form I agree to having my electronic items described below managed for reuse or recycling through the City HHW Program in partnership with the Surplus Exchange. The City does not represent that I am eligible for a charitable tax deduction as a result of using this service.

The City does not accept liability for loss of confidential data or software. By completing and signing this form, I am accepting responsibility for all confidential data that may be stored on the equipment. Before dropping off the equipment for reuse/recycling, I am responsible for: (a) deleting the data on the hard-disk drives and any other storage devices in the equipment; (b) backing up or transferring any data prior to deletion; and (c) removing any removable media, such as diskettes, CDs, or PC cards.

By completing and signing this form I certify that I am a resident of Olathe, Kansas residing at the address provided below.

Name: Print

Address: Number Street City State Zip

NOW, THEREFORE, after reading the above; I agree to indemnify, hold harmless, and defend the City of Olathe, Kansas, it's officials and employees; and release and forever discharge said City of Olathe, Kansas, its officials and employees from any and all causes of action, claims and demands whatsoever, which I, my heirs, executors or administrators, growing out of any injury and/or property damage; or by reason of any cause, matter or thing whatsoever, which may arise from the possession, transport, storage, reuse, recycling or disposal of the Electronic Waste equipment. In making this release, I am relying on my own judgment, belief and knowledge, and I am not relying on anyone representing the City or employed by them. I the undersigned, hereby voluntarily sign this instrument with no promise or representations made to me other than the agreements and considerations herein expressed.

Signature: Date: