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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
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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