Customer Name:
Current Address -  Street:
City, State, Zip Code:
Final Destination - Street:
City, State, Zip Code:
Estimated Date of Move:
Home Phone: 
Cell Phone: 
Work Phone:
E-Mail Address:  

 
Information about your present address:
What are you moving FROM? Home Apartment Storage Unit
What main intersection is this location near?  
Are there stairs/elevators?  Yes    No 
If so, what floor are you moving FROM?     First floor Second Floor Third Floor Fourth Floor Above Fourth Floor
How far is distance from the parking lot/driveway to front door? 

Information about your final destination address:
What are you moving TO?

 Home

Condo Apartment
 Storage Unit

What main intersection is this location near?  
Are there stairs/elevators?  Yes    No 
If so, what floor are you moving TO?  First floor Second Floor Third Floor Fourth Floor Above Fourth Floor
How far is distance from the parking lot/driveway to front door? 
Additional stops:
Will there be any additional stops other than the two above?   Yes    No 
If so, what will the stop be for?    Home Apartment Storage Unit
What main intersection is this location near?  
Are there stairs/elevators?  Yes    No 
If so, what floor are you moving FROM?  First floor Second Floor Third Floor Fourth Floor Above Fourth Floor
How far is distance from the parking lot/driveway to front door? 
Please mark the NUMBER of each of the items listed below you will need moved.
LIVING ROOM / DEN:
  Sofa   Loveseat   Sleeper   Bookcase
  Coffee Table   End Table   Sofa Table   Étagère
  Chair   Ottoman   Rocker   Recliner
  Wall Units   Stereo   Ster. Console   Cabinet
  Speakers   Port. TV   Console TV   TV Stand
  Pit Group (Number of pieces)   Big Screen TV
Do any of the items above have glass or marble?  Yes      No
   If so, state which pieces 
Will any of the above items need disassembly or assembly?  Yes      No
   If so, state which pieces 
DINING/BREAKFAST ROOM:
  Dining Room Table   Chairs   Buffet
  Breakfast Table   Server   Baker's Rack
  China Cabinet  (1 or 2 pc.)
Do any of the items above have glass or marble?  Yes      No
   If so, state which pieces 
Will any of the above items need disassembly or assembly?  Yes      No
  If so, state which pieces 
BEDROOM(S): (Please mark the total number for all bedrooms)
  King Bed   Queen Bed   Double Bed
  Twin Bed   Full Bed   Bunk Bed
  Waterbed   Crib   Dresser
  Chester   Hope Chest   Jewelry Chest
  Vanity   Nightstand   Entertainment Center
  Bookcases   Portable TV   Console TV
  Chairs   Stereo   Speakers
  Trunk   Armoire   Mirror
  Desk   (Describe:  exec., "L" shape, hutch, etc.) 
Any other items not listed? 
Do any of the items above have glass or marble?  Yes      No
   If so, state which pieces 
Will any of the above items need disassembly or assembly?  Yes      No
  If so, state which pieces 
OFFICE FURNITURE:
  Credenza   File Cabinet  (2, 3, 4, or 5 drawers)   Chairs
APPLIANCES / MISC. ITEMS:
  Washer   Dryer   Stove   Refrigerator
  Microwave   Micro Cart   Vacuum   Ironing Board
PATIO / RECREATIONAL:
  Patio Table   Chairs   Bike   BBQ Pit
  Garden Tools   Weight Bench    (Pounds in weights:) 
  Exercise Bike   Push Mower   Riding Mower   Trash Cans
  Exercise Equipment     (Describe:)
  Plants (2 to 4 ft)   Plants (5 to 7 ft)
Will any of the above items need disassembly or assembly?  Yes      No
  If so, state which pieces 
MISCELLANEOUS ITEMS:
  Spinit Piano   Upright Piano   Organ   Pool Table
  Swing Set   Jungle Jim   Lg. Toys   Game Table
  Video Machine   Jukebox
BOXES:
  One man size (40# or less)   Two man size (40# - 60#)
  Wardrobes   Dishpacks   Miscellaneous
If there are any items you will need us to move that are not included in the above inventory, please describe the items below.