Name (required)
Company/Organization
Street Address
City
State/Province Zip Code
Home phone:
Work phone:
Fax Number
E-Mail Address (required)
Where are you moving from?	City State Zip
Type of home you're moving from?	Choose One House Townhouse Apartment (1st Floor) Apartment (2nd Floor) Apartment (3rd Floor or Above) Storage
Is there an elevator?	Choose One Yes No
Where are you moving to?	City State Zip
Target moving date
HOUSEHOLD INFORMATION
Total number of rooms:	Choose One 1 2 3 4 5 6 7 8 9 10 or more
Stairs?	Choose One None One flight Two flights Three flights More than 3 flights
Please check the following rooms to be moved:
Kitchen	Den/Family Room
Laundry Room	Office
Garage	Basement
Living Room	Attic
Dining Room	Outside Building(s)
Porch
Number of bedrooms:	Choose One 1 2 3 4 5 6 7 8 9 or more
Please enter the number of each type of item. If an item is not listed, please include it in the comments box below. LIVING ROOM Bar, Portable 0 1 2 3 4 5 6 7 8 9 or more Piano, Spinet/Console 0 1 2 3 4 5 6 7 8 9 or more Bench, Frsd/Piano 0 1 2 3 4 5 6 7 8 9 or more Radio, Table 0 1 2 3 4 5 6 7 8 9 or more Bookcase 0 1 2 3 4 5 6 7 8 9 or more Rec. Player, Port. 0 1 2 3 4 5 6 7 8 9 or more Bookshelves, Sect. 0 1 2 3 4 5 6 7 8 9 or more Rugs, Lg. Roll/Pad 0 1 2 3 4 5 6 7 8 9 or more Cabinet, Curio 0 1 2 3 4 5 6 7 8 9 or more Rugs, Sm. Roll/Pad 0 1 2 3 4 5 6 7 8 9 or more Chair, Straight 0 1 2 3 4 5 6 7 8 9 or more Sofa, Rattan/Wicker 0 1 2 3 4 5 6 7 8 9 or more Chair, Arm 0 1 2 3 4 5 6 7 8 9 or more Sofa, Sec. Per Sec. 0 1 2 3 4 5 6 7 8 9 or more Chair, Rocker 0 1 2 3 4 5 6 7 8 9 or more Sofa, Loveseat 0 1 2 3 4 5 6 7 8 9 or more Chair, Occasional 0 1 2 3 4 5 6 7 8 9 or more Sofa, 3 cushion 0 1 2 3 4 5 6 7 8 9 or more Chair, Overstuffed 0 1 2 3 4 5 6 7 8 9 or more Sofa, Hide, 4 Cush 0 1 2 3 4 5 6 7 8 9 or more Chest, Cedar 0 1 2 3 4 5 6 7 8 9 or more Stereo Component 0 1 2 3 4 5 6 7 8 9 or more Clock, Grandfather 0 1 2 3 4 5 6 7 8 9 or more Stereo, Console 0 1 2 3 4 5 6 7 8 9 or more Day Bed 0 1 2 3 4 5 6 7 8 9 or more Tables, Drop/Occas 0 1 2 3 4 5 6 7 8 9 or more Desk, SM/Winthrop 0 1 2 3 4 5 6 7 8 9 or more Tables, Coffee 0 1 2 3 4 5 6 7 8 9 or more Desk, Secretary 0 1 2 3 4 5 6 7 8 9 or more Tables, End 0 1 2 3 4 5 6 7 8 9 or more Fireplace Equipment 0 1 2 3 4 5 6 7 8 9 or more Telephone Stand 0 1 2 3 4 5 6 7 8 9 or more Footstool 0 1 2 3 4 5 6 7 8 9 or more TV, Bigscreen 0 1 2 3 4 5 6 7 8 9 or more Hall Tree Rack 0 1 2 3 4 5 6 7 8 9 or more TV, Portable 0 1 2 3 4 5 6 7 8 9 or more Hall Tree Large 0 1 2 3 4 5 6 7 8 9 or more TV, Table Model 0 1 2 3 4 5 6 7 8 9 or more Lamp, Floor 0 1 2 3 4 5 6 7 8 9 or more TV, Console 0 1 2 3 4 5 6 7 8 9 or more Lamp, Pole 0 1 2 3 4 5 6 7 8 9 or more TV, Combination 0 1 2 3 4 5 6 7 8 9 or more Magazine Rack 0 1 2 3 4 5 6 7 8 9 or more TV, Stand 0 1 2 3 4 5 6 7 8 9 or more Music Cabinet 0 1 2 3 4 5 6 7 8 9 or more Trunk 0 1 2 3 4 5 6 7 8 9 or more Piano, Baby Gr/Upr 0 1 2 3 4 5 6 7 8 9 or more Piano, Parlor, GR 0 1 2 3 4 5 6 7 8 9 or more DINING ROOM Bench, Harvest 0 1 2 3 4 5 6 7 8 9 or more Dining Chair 0 1 2 3 4 5 6 7 8 9 or more Buffet (Base) 0 1 2 3 4 5 6 7 8 9 or more Dining Chair 0 1 2 3 4 5 6 7 8 9 or more Hutch (Top) 0 1 2 3 4 5 6 7 8 9 or more Tea Cart 0 1 2 3 4 5 6 7 8 9 or more Cabinet, Corner 0 1 2 3 4 5 6 7 8 9 or more Rugs, Large or Pad 0 1 2 3 4 5 6 7 8 9 or more Dining Table 0 1 2 3 4 5 6 7 8 9 or more Rugs, Small or Pad 0 1 2 3 4 5 6 7 8 9 or more BEDROOM Bed Incl Sp/Matt 0 1 2 3 4 5 6 7 8 9 or more Chest, Armoire 0 1 2 3 4 5 6 7 8 9 or more Bed Rollaway 0 1 2 3 4 5 6 7 8 9 or more Desk, SM/Winthrop 0 1 2 3 4 5 6 7 8 9 or more Bed, Single/Hollywood 0 1 2 3 4 5 6 7 8 9 or more Dresser/Vanity Bch 0 1 2 3 4 5 6 7 8 9 or more Bed, Std./Double 0 1 2 3 4 5 6 7 8 9 or more Dresser, Vanity 0 1 2 3 4 5 6 7 8 9 or more Bed, Queen 0 1 2 3 4 5 6 7 8 9 or more Dresser, Single 0 1 2 3 4 5 6 7 8 9 or more Bed, King 0 1 2 3 4 5 6 7 8 9 or more Dresser, Double 0 1 2 3 4 5 6 7 8 9 or more Bed, Bunk (set 2) 0 1 2 3 4 5 6 7 8 9 or more Dresser, Triple 0 1 2 3 4 5 6 7 8 9 or more Bookshelves, Sect. 0 1 2 3 4 5 6 7 8 9 or more Exercise Bike 0 1 2 3 4 5 6 7 8 9 or more Chair, Boudoir 0 1 2 3 4 5 6 7 8 9 or more Lamp, Floor 0 1 2 3 4 5 6 7 8 9 or more Chair, St/Rocker 0 1 2 3 4 5 6 7 8 9 or more Night Table 0 1 2 3 4 5 6 7 8 9 or more Chaise Lounge 0 1 2 3 4 5 6 7 8 9 or more Rug, Large or Pad 0 1 2 3 4 5 6 7 8 9 or more Chest, Bachelor 0 1 2 3 4 5 6 7 8 9 or more Rug, Small or Pad 0 1 2 3 4 5 6 7 8 9 or more Chest, Cedar 0 1 2 3 4 5 6 7 8 9 or more Wardrobe, Small 0 1 2 3 4 5 6 7 8 9 or more Wardrobe, Large 0 1 2 3 4 5 6 7 8 9 or more Waterbed 0 1 2 3 4 5 6 7 8 9 or more NURSERY Bassinette 0 1 2 3 4 5 6 7 8 9 or more Crib, Baby 0 1 2 3 4 5 6 7 8 9 or more Bed, Youth 0 1 2 3 4 5 6 7 8 9 or more Table, Childs 0 1 2 3 4 5 6 7 8 9 or more Chair, Childs 0 1 2 3 4 5 6 7 8 9 or more Playpen 0 1 2 3 4 5 6 7 8 9 or more Chair, High 0 1 2 3 4 5 6 7 8 9 or more Rug, Large or Pad 0 1 2 3 4 5 6 7 8 9 or more Chest 0 1 2 3 4 5 6 7 8 9 or more Rug, Small or Pad 0 1 2 3 4 5 6 7 8 9 or more Chest, Toy 0 1 2 3 4 5 6 7 8 9 or more APPLIANCES Air Cond/Wind Sm. 0 1 2 3 4 5 6 7 8 9 or more Range 36" wide 0 1 2 3 4 5 6 7 8 9 or more Air Cond/Wind. Lg. 0 1 2 3 4 5 6 7 8 9 or more Refrigerator (CuCp) 0 1 2 3 4 5 6 7 8 9 or more Dehumidifier 0 1 2 3 4 5 6 7 8 9 or more Ref. 6 cu. ft. or less 0 1 2 3 4 5 6 7 8 9 or more Dishwasher 0 1 2 3 4 5 6 7 8 9 or more Ref. 7-10 cu. ft. 0 1 2 3 4 5 6 7 8 9 or more Freezer 0 1 2 3 4 5 6 7 8 9 or more Ref. 11 cu. ft. or more 0 1 2 3 4 5 6 7 8 9 or more Freezer 10 or less 0 1 2 3 4 5 6 7 8 9 or more Trash Compactor 0 1 2 3 4 5 6 7 8 9 or more Freezer 11-15 0 1 2 3 4 5 6 7 8 9 or more Vacuum Cleaner 0 1 2 3 4 5 6 7 8 9 or more Freezer 16 or over 0 1 2 3 4 5 6 7 8 9 or more Washing Machine 0 1 2 3 4 5 6 7 8 9 or more Range 20" wide 0 1 2 3 4 5 6 7 8 9 or more Dryer 0 1 2 3 4 5 6 7 8 9 or more Range 30" wide 0 1 2 3 4 5 6 7 8 9 or more KITCHEN Bkft. Suite, ChairsBkft. Suite, Chairs 0 1 2 3 4 5 6 7 8 9 or more Microwave Oven 0 1 2 3 4 5 6 7 8 9 or more Breakfast Table 0 1 2 3 4 5 6 7 8 9 or more Serving Cart 0 1 2 3 4 5 6