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We would apppreciate it if you would take a few moments to answer the following questions.  Please be assured that we do not  share or sell personal information about you except when we have your permission.


* Required item 

Date of move (MM/DD/YY):
    
First Name*
 Middle Initial
 Last Name*
 
Address
Email Address*
 Phone Number
Origin (Moving from?)
City*
State*
Zip Code*
Destination (Moving to?)
City*
State*


Zip Code*
Living Room:
Quantity
  Sofa   Loveseat   Hide-A-Bed
  Sectional-Enter Number of Pieces   Ottoman/Footstool   Pictures
  Armchairs   Rockers   Overstuffed Chair
  Recliner Chair   Recliner Loveseat   Recliner Sofa
  Coffee Table   End Table   Sofa/Occasional Table
  Table Lamps   Floor Lamps   Bookcase
  Entertainment Center 1 Piece   Upright Piano   TV Stand
  Entertainment Center 2 Piece   Floor Speakers   Stereo Stand
  Entertainment Center  3 Piece   Organ   Butcher Block/Island

Bedroom:
Quantity
  King Size Bed   Queen Size Bed   Full Size Bed
  Twin Bed   Bunk Bed   Bridge Headboard
  Head/Footboard   Dresser Double   Dresser Triple
  Mirror (Detached)   Pedestal Bedframe   Canopy Top
  Sleigh Bedframe   Vanity   Linear Feet of Clothes on Rod
  Chest of Drawers   Armoire/Wardrobe (empty)   Nightstand
  Cedar Chest or Trunk   Crib or Changing Table    


Dining Room:
Quantity
  Dining/Kitchen Table   Dining Chairs or Bar Stools
  China Cabinet (1 or 2 piece)   Buffet or Server


Appliances/Electronics:
Quantity
  Stove or Oven   Dorm Fridge   Electronic Components (Speakers, VCR's, Etc.)
  Refrigerator Standard   Refrigerator Side By Side   Freezer
  Washer   Dryer   Pedestal for Washer or Dryer
  Television 1-29"   Television 30-39"   Television 40+"
  Microwave   Microwave Stand    

Office:
Quantity
  Small Desk   Medium Desk   Large Office or Roll Top Desk
  Desk Extension   Desk Chair   Fire Proof File Cabinet
  Credenza   2 Drawer Filing Cabinet   4 Drawer Filing Cabinet
  2 Drawer Lateral Filing Cabinet   4 Drawer Lateral File Cabinet   Gun Cabinet
  Conference Table   Drafting Table   Fireproof Gun Safe
  Copier   Computer   Printer
  Printer Stand
 		  
 		  

Miscellaneous:
Quantity
  Boxes Less Than 50 lbs.   Glass Tops   Area Rugs
  Boxes MORE Than 50 lbs.   Marble Tops   Barbeque
  Large Plants   Sewing Machine   Extension Ladder
  Ironing Board   Vacuum   Rolling Tool Chest
  Plant Stand   Step Ladder   Pool Table
  Patio Tables   Concrete Bench   Bicycles
  Patio Chairs   Concrete Table   Riding Mower
  Golf Clubs   Toy Box   Push Mower
  Suitcases   Workbench   Bird Bath
  Yard Tools        
  

Important:  What is the distance between the front door and where the movers park?

Origin:
  Less than 100 ft.      
  More than 100 ft.       
 
Destination:
  Less than 100 ft.      
  More than 100 ft.      
  

Please mark all that apply:
Origin:
Elevators      
  Stairs Number of Flights         

Destination:
Elevators      
  Stairs Number of Flights         

Additional comments: