Date of Expected Move:     Date You Would Like An Estimate:     Time:

Type of Move: Local    Long Distance    Military

Customer First Name:     Last Name:

Move From Address:

City From :     State From:     Zip Code From:

Approximate Square Footage of "Move From" Address: square feet

Home Phone:     Work Phone:     Fax Number:

Move To Address:

City To:     State To:     Zip Code To:

Approximate Square Footage of "Move To" Address: square feet

Do you require packing services?      Yes    No

Do you require boxes or cartons for shipping?    Yes    No

Do you require storage for any of your items?    Yes    No

Do you require any additional stops to deliver items elsewhere?    Yes    No

Additional information you would like us to know: