State of Tennessee

Tennessee Department of Environment and Conservation  - Office of Sustainable Practices 
William R. Snodgrass Tennessee Tower; 312 Rosa L. Parks Avenue; 2nd Floor | Nashville, TN 37243 
PH: 615-253-8780 | FAX: 615-532-0120 | Kathy.Glapa@tn.gov

FY 2021-2022 Pharmaceutical Take Back Application
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Law Enforcement Agency Name*

LE Agency Address*

Address Line 1

Address Line 2

City

State

ZIP Code

LE Agency County*

Is the bin location the same as LE agency address?*

Yes No

Pill Take Back Box Address

Address Line 1

Address Line 2

City

State

ZIP Code

Point of Contact (POC) Name*

First Name

Last Name

POC Email*

POC Phone Number*

Secondary POC Name

First Name

Last Name

Secondary POC Email

Secondary POC Phone Number

Applicant Signature*

[clear]

Use your mouse or finger to draw your signature above.

Date of Application*

FY 2021-2022 Pharmaceutical Take Back Application________________________________________________________________________________

FY 2021-2022 Pharmaceutical Take Back Application
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