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Customer Information
Name Home Phone
Address Work Phone
City State ZIP Code Cell Phone
E-Mail Fax Number
 
New Address  
New City New State New ZIP  
Approx. Move Date  
 
Distance (in ft) from where the truck can park to your front door: Current Home/Apt New Home/Apt
Number of flights of stairs to current front door (Over 8 steps): Current Home/Apt Elevator Available?
Number of flights of stairs to new front door (Over 8 steps): New Home/Apt Elevator Available?
How would you like to be contacted with your price?      
How did you hear about us?
Special Notes:      
Living Rm
Family Rm		 Qty Bedroom
Den/Office		 Qty Kitchen
Dinning Rm		 Qty Basement
Attic/Misc.		 Qty Office / Shop
Misc.		 Qty
Bar - Portable Armoire Bakers Rack ELECTRONICS   Barbell lbs
Bench Baby Carriage Bench     Basket / Hamper
Bookcase Bed, Rollaway Buffet, Base Computer Desk Bicycle
Bookcase - Section Bed, Youth Chair, Dining Room Computer Piece Bird Bath / Fountain
Cabinet Bed, Single Chair, Kitchen Entertainment Cntr Bowling Ball / Bag
Cabinet, Curio Bed, Double Corner Cabinet Stereo Component Card Table
Chair, Occasional Bed, Queen Hutch, Top TV - 19" or Less Chairs, Folding
Chair, Overstuff Bed, King Ironing Board TV - 20" to 40" Desk, Office
Chair, Rocker Bed, Bunk / Trundle Microwave Cart TV - Over 40" Exercise Machine
Chair, Straight Bench, Vanity Serving Cart TV - Plasma Exer-cycle
Clock, Grandfather Chair, Boudoir Stool TV Trays Fan
Desk, Small/Winthrop Chaise Lounge Table, Dining Room     File Cab. Cardboard
Desk, Secretary Chair, Childs Table, Kitchen BBQ File Cab. 2 Drawer
Fireplace Equipment Changing Table Tea Cart BBQ Over 150 lbs File Cab. 4 Drawer
Foot Stool Chest, Bachelor Utility Cabinet Chairs, Alum. Golf Clubs
Futon Chest, Cedar Water Cooler Chairs, Metal Hot Tub
Hall Tree Rack Chest, Toy     Chairs, Wood Metal Shelves
Hall Tree Large Crib APPLIANCES   Garden Hose / Tool Ping Pong Table
Lamp, Floor / Pole Dresser, Vanity     Glider / Settee Pool Table Comp
Piano - Baby / Upright Dresser, Single Air Conditioner Ladder 6' Step Pool Table Slate
Piano - Parlor / Grand Dresser, Double Clothes Dryer Ladder 8' Step Port BB Hoop
Piano - Spinet Dresser, Triple Clothes Washer Lawn Mower Power Tool, Hand
Plant - Small
 Night Table Freezer, <10 cf Lawn Mower, Rider Power Tool & Stand
Rug - Large Roll Playpen Freezer, 11-16 cf Leaf Sweeper Sewing Mach, Port.
Rug - Small Table, Childs Freezer, >16 cf Outdoor Slide Sewing Mach w/ Cab.
Sofa - Loveseat Trunk / Foot Locker Microwave Outdoor Gym Suitcase
Sofa - 3 Cusion Wardrobe, Small Refrigerator < 10 cf Outdoor Swing Table, Utility
Sofa - 4 Cusion Wardrobe, Large Refrigerator > 10 cf Picnic Table Tool Chest, Small
Sofa - Hide-A-Bed     Stove / Range Picnic Bench Tool Chest, Medium
Sofa - with Recliners BOXES   Vacuum Cleaner Spreader, Lawn Tool Chest, Large
Table - Coffee / End         Table, Small Trash Can
Table - Drop / Occas Boxes, Small     Table, Large Tricycle
    Boxes, Medium     Umbrella Wagon, Childs
    Boxes, Large     Wheel Barrow Work Bench
               
            Use these Boxes for Any Unlisted Items  
            Other
            Other
            Other
            Other
            Other
            Other

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