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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 Armoire Bakers Rack Air Conditioner Bar BQ / Grill
Bench Bassinet Bench Baby Carriage Bike
Bookcase Bed - Single Buffet Boxes - Large Garbage Can
Chair, Arm Bed - Double Chair Boxes - Small Glider
Chair, Overstuff Bed - Queen Chair, High Card Table Hose
Chair, Recliner Bed - King China Cabinet Chair - Folding Hot Tub
Chair, Rocker Bed - Bunk / Trundle Corner Cabinet Clothes Basket Ladder - Extension
Clock, Grandfather Bed - Water, Assem Curio Cabinet Cooler Ladder - Step
CD / Video Rack Bed - Water, Disass Dry Sink Cot Lawn Cart
Desk, Small Bookcase Hutch Fan Lawn Chair
Desk, Large Cedar Chest Ironing Board Foot Locker Lumber
Electronics Chair, Childs Microwave Golf bag Metal Shelves
Entertainment Center Changing Table Microwave Cart Gun Cabinet Motorcycle
Fireplace Equipment Computer Pieces Serving Cart Gun Safe Mower - Push
Foot Stool Copier Stool Metal Shelve Mower - Riding
Hall Chest Credenza Table, Dining Pet Cage Outdoor Sculpture
Lamp Crib Waste Basket Ping Pong Table Outdoor Tools
Picture Desk - Large Water Cooler Pool Table Patio Chair
Piano - Spinet Desk - Small Tea Cart Power Tool Patio Table
Piano - Upright Dresser - Chest     Sports Equipment Patio Umbrella
Piano - Baby Grand Dresser - Double Appliances   Storage Cabinet Picnic Bench
Piano - Grand Dresser - Triple Clothes Dryer Suitcase Picnic Table
Plant - Small Exercise Equipment Clothes Washer Table - Folding Planter
Plant - Large File Cabinet - Large Dehumidifier Table - Utility Portable BB Hoop
Rug - Small File Cabinet - Small Dishwasher Tackle Box Sled
Rug - Large File Cabinet - Lat. Freezer Tool Chest Snow Blower
Sofa - 2 Cusion Futon Humidifier Toy Chest Storage Cabinet
Sofa - 3 Cusion Hamper Refrigerator - Dorm Toys - Large Swing Set
Sofa - 4 Cusion Hanging Clothes 2' Refrigerator Trunk Tires
Sofa - Hide-A-Bed Mirror Stove / Range Work Bench Tricycle
Sofa - with Recliners Night Table Vacuum Cleaner     Wheel Barrow
Speakers Playpen            
Stereo Cabinet Sewing Machine            
Table - Coffee / End Treadmill            
Table - Drop / Occas Vanity     Other
TV - (19" or Less) Wardrobe Closet     Other
TV - (20" - 40") Work Table     Other
TV - (Over 40")         Other
TV / Snack Tray         Other
TV Stand         Other

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