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First Name:*
Last Name:*
E-mail:*
Phone:*
Move Date:
Moving From Moving To
Current Dwelling:
State, Zip:  
No. of Flights or Stairs:
(Flight is approx. 10-12 stairs)
Packing Required:
 Yes No
Dwelling:
State, Zip:    
No. of Flights or Stairs:
(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: