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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
Arm Chair Armoire Bakers Rack Bar - Portable Air Conditioner
Bookcase - Large Bassinet Bench Card Table Set Bar BQ / Grill
Bookcase - Small Bed - Single Buffet Clothes Dryer Bike
CD / Video Rack Bed - Double Chair Clothes Washer Garbage Can
Coffee / End Table Bed - Queen China Cabinet Cooler Glider
Electronics Bed - King Compactor Cot Hose
Enter. Center Bed - Bunk, Trun. Corner Cabinet Dehumidifier Ladder
Fire Place Equip Bed - Water, Assem. Curio Cabinet Fan Lawn Cart
Foot Stool Bed - Water, Diss. Dishwasher Foot Locker Lawn Chair
Grandfather Clock Bookcase - Large Hutch Freezer Lawn Mower
Hall Chest Bookcase - Small Ironing Board Gun Cabinet Lumber
Lamp Cedar Chest Mircrowave Humidifier Metal Shelves
Piano - Baby Grand Changing Table Mircrowave Cart Metal Shelves Outdoor Sculpture
Piano - Spinet Clothes Tree Refrigerator Ping Pong Table Outdoor Tools
Piano - Upright Computer Pieces Rug Pool Table Patio Chair
Picture Credenza Serving Cart Power Tools Patio Table
Plant - Large Crib Stool Sports Equip Picnic Bench
Plant - Small Desk - Chair Stove Range Storage Cabinet Picnic Table
Recliner / Rocker Desk Computer Table Suitcase Planter - Large
Sofa - 2 Cusion Desk - Large Vacuum Cleaner Table - Folding Planter - Small
Sofa - 3 Cusion Desk - Small Waste Basket Tool Chest Port. BB Hoop
Sofa - Hide-a-Bed Dresser / High Boy Water Cooler Toy Chest Riding Mower
Sofa w/ Recliner
Exercise Equip     Toys - Large Sand Box
Speakers File Cabinet - Large     Trunk Snow Blower
Stereo Cabinet File Cabinet - Small     Work Bench Storage Cabinet
TV 19" or less Futon     Hoisting Service Swing Set
TV 20" - 40" Hamper         Umbrella
40" Plus Hang Clothes / 2 Feet     Total Boxes - Sm Tires
TV Stand Mirror     Total Boxes - Lg Wheel Barrow
TV Snack Trays Night Table            
Wall Unit Pieces Sewing Machine            

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