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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
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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