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First Name:*
Last Name:*
E-mail:*
Phone:*
Move Date:
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2008
2009
2010
2011
Moving From
Moving To
Current Dwelling:
Storage
Studio
College dorm
College apartment
Condo
1 bedroom apt.
2 bedroom apt.
3 bedroom apt.
1 bedroom home
2 bedroom home
3 bedroom home
4 bedroom home
5 bedroom home
State, Zip:
AL
Alberta
AK
American Samoa
AZ
AR
British Columbia
CA
CO
CT
DE
DC
FL
GA
Guam
HI
ID
IL
IN
IA
KS
KY
LA
ME
Manitoba
Marshall Islands
MD
MA
Micronesia
MI
MN
MS
MO
MT
NE
New Brunswick
Newfoundland
NV
NH
NJ
NM
NY
NC
ND
Marianas Islands
Northwest Territories
Nova Scotia
Nunavut
OH
OK
Ontario
OR
Palau
PA
Prince Edward Islands
Puerto Rico
Quebec
RI
SC
SD
Saskatchewan
TN
TX
U.S Virgin Islands
UT
VT
VA
WA
WV
WI
WY
Yukon Territory
No. of Flights or Stairs:
Elevator
Ground Floor
1
2
3
4
5
6
7
8
9
10
11
12+
(Flight is approx. 10-12 stairs)
Packing Required:
Yes
No
Dwelling:
Storage
Studio
College dorm
College apartment
Condo
1 bedroom apt.
2 bedroom apt.
3 bedroom apt.
1 bedroom home
2 bedroom home
3 bedroom home
4 bedroom home
5 bedroom home
State, Zip:
AL
Alberta
AK
American Samoa
AZ
AR
British Columbia
CA
CO
CT
DE
DC
FL
GA
Guam
HI
ID
IL
IN
IA
KS
KY
LA
ME
Manitoba
Marshall Islands
MD
MA
Micronesia
MI
MN
MS
MO
MT
NE
New Brunswick
Newfoundland
NV
NH
NJ
NM
NY
NC
ND
Marianas Islands
Northwest Territories
Nova Scotia
Nunavut
OH
OK
Ontario
OR
Palau
PA
Prince Edward Islands
Puerto Rico
Quebec
RI
SC
SD
Saskatchewan
TN
TX
U.S Virgin Islands
UT
VT
VA
WA
WV
WI
WY
Yukon Territory
No. of Flights or Stairs:
Elevator
Ground Floor
1
2
3
4
5
6
7
8
9
10
11
12+
(Flight is approx. 10-12 stairs)
Unpacking Required:
Yes
No
Storage Required:
Yes
No
Enter the number of items for each room below.
Living Room
Bar, Portable
Bookcase
Bookshelves, Sectional
Cabinet, Curio
Chair, Arm
Chair, Occasional
Chair, Overstuffed
Chair, Rocker
Chair, Straight
Clock, Grandfather
Day Bed
Desk, Small
Desk Secretary
Foot Stool
Hideabed or Studio Couch
Lamp, Floor or Pole
Music Cabinet
Organ
Piano, Baby Grand or Upright
Piano, Parlor Grand
Piano, Spinet
Rug, Large Roll or Pad
Rug, Small Roll or Pad
Sofa, 2 Cushions
Sofa, 3 Cushions
Sofa, 4 Cushions
Sofa, Sectional
Table, Coffee, End or Night
Dining Room
Bench, Harvest
Buffet
Cabinet, China
Cabinet, Corner
Chair, Dining
Hutch
Rugs, Large or Pad
Rugs, Small or Pad
Server
Table, Dining
Tea Cart
Electronics
Entertainment Center
Home Computer/Printer
Stereo Component
Stereo Console
TV - Portable
TV - Table Model
TV - Console
TV - Screen
TV Stand
Typewriter - Portable
Bedroom
Bed, Bunk (2)
Bed, Spring & Mattress, Bunk (2)
Bed, Double
Bed, King Size
Bed, Queen Size
Bed, Rollaway
Bed, Single or Hollywood
Bench, Vanity
Bookshelves, Sectional
Bureau, Dresser, Chest of Drawers
Cedar Chest
Chair, Boudoir
Chair, Straight or Rocker
Chaise Lounge
Chest, Armoire
Desk, Small or Wintrop
Dresser, Double
Dresser, Vanity
Night Table
Rug, Large or Pad
Rug, Small or Pad
Wardrobe, Large
Wardrobe, Small
Nursery
Bathinette
Bed, Youth
Chair, Child
Chair, High
Chest
Chest, Toy
Crib, Baby
Play Pen
Rug, Large or Pad
Rug, Small or Pad
Table, Child
Kitchen
Breakfast Suite Chairs
Breakfast Table
Chair, High
Ironing Board
Kitchen Cabinet
Serving Cart
Stool
Table
Utility Cabinet
Appliances
Air Conditioner, Window
Dehumidifier / Humidifier
Dishwasher
Dryer, Electric or Gas
Freezer (Cu. Capacity) 10 or less
Freezer (Cu. Capacity) 11 to 15
Freezer (Cu. Capacity) 16 & over
Microwave / Convection Oven
Range, Electric or Gas
Refrigerator (Cu. Capacity) 10 or less
Refrigerator (Cu. Capacity) 11 to 15
Refrigerator (Cu. Capacity) 16 & over
Trash Compactor
Vacuum Cleaner
Washing Machine
Outdoor
Barbecue or Portable Grill
Birdbath
Chairs, Lawn
Chairs, Porch
Game Table
Garden Hose & Tools
Glider or Settee
Ladder, Extension
Ladder, Step
Lawn Mower, Hand
Lawn Mower, Power
Lawn Mower, Riding
Outdoor Swings
Picnic Bench
Picnic Table
Rocker, Swing
Roller, Lawn
Rug, Large
Customer Signature
Name:
Date: