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Customer Information
Name
Home Phone
Address
Work Phone
City
State
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WV
WI
WY
ZIP Code
Cell Phone
E-Mail
Fax Number
New Address
New City
New State
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WV
WI
WY
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?
Home Phone
Email
Cell Phone
Work Phone
Fax Machine
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
BEDROOM
DINING ROOM
Baby Carriage
BBQ Grill Small
Bench, Frsd. Piano
Bed Incl Sp/Matt
Bench, Harvest
Barbells
BBQ Grill Large
Bookcase - Large
Bed - Water-Base
Buffet (Base)
Basket, Clothes
Chair, Aluminum
Bookshelves, sec.
Bed - Roll-A-Way
Hutch (Top)
Bicycle
Chair, Metal
Cabinet, Curio
Bench
Cabinet, Corner
Tricycle
Chair, Wood
Chair, Straight
Bed - Sgl / Hllywd
Dining Table
Bowling Ball / Bag
Garden Hose / Tool
Chair, Arm
Bed - Standard / Double
Dining Chair
Card Table
Glider or Settee
Chair, Rocker
Bed - Queen
Server
Folding Chairs
Ladder - 6' Step
Chair, Occasional
Bed - King
Tea Cart
Clothes Hamper
Ladder - 8' Step
Chair, Overstuff
Bed - Bunk, Trundle
Rug, Large / Pad
Cot, Folding
Ladder - Extension
Chest, Cedar
Bookshelf, Section
Rug, Small / Pad
Desk, Office
Lawn Mow, Hand
Clock, Grandfather
Chair, Bourdoir
APPLIANCES
Fan
Lawn Mow, Power
Day Bed
Chair, Standard / Rocker
Air Cond/Wind/Sm
Fern / Plant Stand
Lawn Mow, Ride
Desk, Sml - Winthr
Chaise Lounge
Air Cond/Wind/Lg
Filing Cab. Cardbd
Lawn Sweeper
Desk, Secretary
Chest, Bachelor
Dehumidifier
Filing Cab. 2 Dr.
Outdoor Child Slide
Fireplace Equipment
Chest, Cedar
Dishwasher
Filing Cab. 4 Dr.
Outdoor Child Gym
Foot Stool
Chest, Armoire
Freezer
Foot Locker
Outdoor Dry Rack
Hall Tree Rack
Desk - Small / Winthro
Freezer - 10 / less
Game Table
Picnic Table
Hall Tree Large
Dresser / Vanity / Bch
Freezer - 11 to 15
Golf Bag
Picnic Bench
Lamp, Floor
Dresser, Vanity
Freezer - 16 - Over
Heater, Gas / Elec
Roller, Lawn
Lamp, Pole
Dresser, Single
Range - 20" wide
Metal Shelves
Rug, Large
Magaizine Rack
Dresser, Double
Range - 30" wide
Ping Pong Table
Rug, Small
Music Cabinet
Dresser, Triple
Range - 36" wide
Pool Table Comp.
Sand Box
Piano - Baby Gr - Upr.
Night Table
Refrigerator (cu)
Pool Table Slate
Spreader
Piano - Parlor Grand
Rugs, Large or Pad
Small Bar
Power Tool Hand
Table, Large
Piano - Spinet
Rugs, Small or Pad
Small Bar 7-10 cuft
Power Tool Stand
Umbrella
Radio, Table
Wardrobe, Small
Small Bar 11+ cuft
Sewing Mac Port
Wheel Barrow
Rec, Player, Ptbl
Wardrobe, Large
Trash Compactor
Sewing Mac Cons
Rugs - Lg. Roll - Pad
NURSERY
Vacuum Cleaner
Sewing Mac Cabi
Rugs - Sm. Roll - Pad
Bathinette
Washing Machine
Sled
Sofa, Rattan - Wkr
Bed, Youth
Dryer Gas / Electric
Suitcase
Sofa, Sec, Per
Chair, Childs
KITCHEN
Table - Utility
Sofa - Loveseat
Chair, High
Bkft. Suite, Chair
Tackle Box
Sofa - 3 Cusion
Chest
Breakfast Table
Tire
Sofa - Hida-a-Bed
Chest, Toy
Chair, High
Tire w/ Rim
Stereo Component
Crib, Baby
Iron Board
Tool Chest - Sm
Stereo Console
Table, Childs
Kitchen Cabinet
Tool Chest - Med
Tables, Drop - Occ
Playpen
Mircrowave Oven
Tool Chest - Lg
Tables, Coffee
Rug, Large / Pad
Serving Cart
Trash Can
Tables, End
Rug, Small / Pad
Stool
Wagon, Childs
Telephone Stand
Table
Wastepaper Bask
TV - Portable
Utility Cabinet
Work Bench
TV - Table Model
TV - Console
TV - Combination
Other
TV Stand
Other
Trunk
Other
CARTONS / BOXES
Other
Dish - Pack
Other
Small Box
Other
Medium Box
Large Box
Extra Large Box
Wardrobe Box
Mirror Box
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