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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
Qty Kitchen
Dinning Rm
Qty Basement
Qty Office / Shop
Bench Armoire Bakers Rack Bar - Portable BBQ / Grill
Bookcase - Large Bed- Youth Bench Bar Stool Bike
Bookcase - Small Bed - Single Buffet Card Table Set Garbage Can
Cabinet Bed - Double Cabinet Chair - Folding Glider
CD/Video Rack Bed - Queen Chair - Dining Room Clothes Basket Hose/Reel
Chair - Arm Bed - King Chair - High Cooler Hot Tub
Chair - Occasional Bed - Bunk, Trun. Chair - Kitchen Cot Hammock
Chair - Overstuffed Bed - Water, Assem China Cabinet
(2 Pcs)
Fan Kayak
Chair - Recliner Bed - Water, Disassem. Corner Cabinet Foot Locker Ladder-Extension
Chair - Rocker Bed - Rollaway Curio Cabinet Golf Bag Ladder - Step
Chair - Straight Bookcase - Large Hutch Gun Cabinet Lawn Cart
Clock / Grandfather Bookcase - Small Ironing Board Gun Safe Lawn Chair
Day Bed Chair - Childs Microwave Cart Gym/Workout Ctr Lumber
Desk - Secretary Chair - Desk Serving Cart Juke Box Mower - Hand
Desk - Small Chair - Occasional Stool Locker Mower - Power
Electronics Chair - Rocker Table - Dining Room Pet Cage Mower - Riding
Entertainment Center Cedar Chest Table - Kitchen Ping Pong Table Outdoor Sculpture
Fireplace Equip. Changing Table Tea Cart Pool Table Outdoor Tools
Foot Stool Clothes Tree Waste Basket Power Tool Patio Chair
Hall Chest Computers Water Cooler Projection Screen Patio Table
Lamp - Pole Credenza     Rollaway Picnic Bench
Lamp - Table Crib Appliances Safe - Small Picnic Table
Magazine Rack Desk - Small Safe - Large Planter - Small
Music Cabinet Desk - Large     Shelving Unit Planter - Large
Piano Bench Dresser - Chest Air Conditioner Shop Vac Porch Swing
Piano - Spinet Dresser - Double Clothes Dryer Sports Equipment Port. BBall Hoop
Piano - Upright Dresser - Triple Clothes Washer Storage Cabinet Pressure Washer
Piano - Baby Grand Exercise Equipment Compactor Suitcase Propane Tank
Picture File Cabinet - Small Dehumidifier Table Sand Box
Plant - Small File Cabinet - Large Dishwasher Table - Folding Saw Horse
Plant - Large Futon Freezer <10cf Tackle Box Shelving Unit
Rug - Small Hamper Freezer 10-16cf Tent Skis
Rug - Large Hang Clothes/ 2 ft Freezer >16cf Tool Box Sled
Rug - Pad Mirror Humidifier Tool Chest Snow Blower
Sofa - 2 Cushion Night Table Microwave Toy Chest Storage Cabinet
Sofa - 3 Cushion Playpen Refrig <7cf Toy - Large Stroller
Sofa - 4 Cushion Rug - Small Refrig 7-10cf Trunk Swing Set
Sofa with Recliner Rug - Large Refrig >10cf Work Bench Tires
Sofa - Hide-a-Bed Sewing Machine Stove / Range     Trampoline
Speakers Table - Small Vacuum Cleaner     Tricycle
Stereo Cabinet Vanity     Boxes - Small Umbrella
Table -Coffee -End Wardrobe     Boxes - Medium Wagon
Table - Drop/Occas.         Boxes - Large Wheel Barrow
TV (19" or less)          
TV (20-40")         Other
TV (Over 40")         Other
TV Snack Trays         Other
TV Stand         Other

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