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Contact Information
*Full Name:
*Email Address:
*Home Phone:
Work Phone:					Extension:
Fax:
Estimated Move Date:		January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2009 2010 2011 2012
Pickup Information			Delivery Information
Address:			Address:
City:			City:
State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY     Zip:			State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY     Zip:
Home size:	Studio 1 Bedroom 2 Bedroom 3 Bedroom Private House Storage Office		Home size:	Studio 1 Bedroom 2 Bedroom 3 Bedroom Private House Storage Office
Elevator:	Yes No		Elevator:	Yes No
If walk up, write # of Floors:			If walk up, write # of Floors:
Will you need: Packing Unpacking Storage

Item	Quantity	Item	Quantity	Item	Quantity
Bar Portable		Magazine Rack		Tables, Coffee, End or Nest
Bench, Fireside or Piano		Music Cabinet		Telephone Stand and Chair
Bookcase		Piano, Baby Gr. or Upr.		Television Combination
Bookshelves, sectional		Piano, Parlor Grand		Television or Radio Console
Chair, Arm		Piano, Spinet		Television Table Model
Chair, Occasional		Radio, Table
Chair, Overstuffed		Record Player Port.
Chair, Rocker		Rugs, Large Roll or Pad
Chair, Straight		Rugs, Small Roll or Pad
Clock, Grandfather		Sofa, 2 Cushions
Day Bed		Sofa, 3 Cushions
Desk, Small or Winthrop		Sofa, 4 Cushions
Desk, Secretary		Sofa, Sectional, per sect.
Fireplace Equipment		Stereo
Foot Stool		Stud, Couch and Hideabed
Lamp, Floor or Pole		Tables, Dropl'f Occas.
Dining Room
Bench, Harvest		Chair, Dining		Tea Cart
Buffet		Server		Rugs, Large Roll or Pad
Cabinet, Corner		Table Dining		Rugs, Small Roll or Pad
Cabinet, China
Bedrooms
Bed, Double		Bureau, Dresser, Chest of Drawers		Dresser, Double (Mr. & Mrs.)
Bed, King size		Chair, Boudoir		Night Table
Bed, Single or Hollywood		Chair, Straight or Rocker		Rugs, Large Roll or Pad
Bed, Rollaway		Chaise Lounge		Rugs, Small Roll or Pad
Bed, Bunk (set of 2)		Desk, Small or Winthrop		Vanity Dresser
Bookshelves		Dresser or Vanity Bench		Wardrobe, Small
				Wardrobe, Large
Nursery
Bassinette		Chest		Pen, Play
Bed, Youth		Chest, Toy		Rugs, Large Roll or Pad
Chair, Childs		Crib, Baby		Rugs, Small Roll or Pad
Chair, High		Table, Child
Kitchen
Breakfast, Suite Chairs		Kitchen Cabinet		Table
Breakfast Table		Roaster		Utility Cabinet
Chair, High		Serving Cart		Vegetable Bin
Ironing Board		Stool
Appliances
Air Conditioner		Freezer, Cu. Capacity **please select below**		Refrigerator, **please select below**
Dehumidifier		10 Cubic Feet or Less		6 Cubic Feet or Less
Dishwasher		11 to 15 Cubic Feet		7 to 10 Cubic Feet
Dryer, Electric or Gas		16 Cubic Feet and Up		11 Cubic Feet or More
Vacuum Cleaner
Washing Machine
Porch, Outdoor Furniture and Equipment
Barbeque or Port. Grill		Lawn Mower, Power		Rocker, Swing
Bath, Bird		Lawn Mower, Riding		Roller, Lawn
Chairs, Lawn		Leaf Sweeper		Rug, Large
Chairs, Porch		Outdoor Child's Slide		Rug, Small
Clothes Line		Outdoor Child's Gym		Sand Box
Clothes Dryer Rack		Outdoor Drying Rack		Settee
Garden Hose and Tools		Outdoor Swings		Spreader
Glider or Settee		Picnic Table		Table
Ladder, Extension		Picnic Bench		Umbrella
Lawn Mower, Hand		Porch Chair		Wheel Barrow
Miscellaneous
Ash or Trash Can		Fan		Sewing Machine
Basket (Clothes		Fernery or Plant Stands		Sled
Bicycle		Foot Lockers		Step Ladder
Bird Cage and Stand		Garbage Cans		Suitcase
Card Table		Golf Bag		Table, Utility
Cabinet, Filing		Heater, Gas or Electric		Tackle Box
Carriage, Baby		Incinerator		Tool Chest
Chairs, Folding		Metal Shelves		Tricycle
Clothes Hamper		Ping Pong Table		Wagon, Child's
Cot, Folding		Pool Table		Waste Paper Basket
Desk, Office		Power Tools		Work Bench

Additional Items		Qty	Order Boxes		Qty
			Book Box-Small
			Linen Box-Medium
			China Box-Large
			Picture Box-Large
			Wardrobe
			White Paper
Additional Comments