| Your Name: |
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| Email Address: |
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| Daytime Phone: |
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| Evening Phone: |
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| Where did you hear about us? |
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| When are you planning to move? |
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| Address you are moving from: |
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| This location is a: |
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| How many flights of stairs? |
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| Address you are moving to: |
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| This location is a: |
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| How many flights of stairs? |
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| Just fill out the list below with the total number of each item. You are not limited to just numbers. Please feel free to include any short note and/or description. |
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| Sofa or Couch (not a sleeper or hide-a-bed): |
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| Love Seat (not a sleeper or hide-a-bed): |
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| Sleeper Sofa or Hide-A-Bed: |
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| Recliner Sofa (sofa with built in recliners): |
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| Piece Sectional Sofa (each piece): |
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| Futon and Frame: |
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| Rockers, Recliners or Arm Chairs: |
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| Ottoman or Foot Stool: |
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| Coffee or Sofa Tables: |
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| End Tables: |
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| Entertainment Center (how many pieces?): |
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| Grandfather Clock (pendulums removed): |
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| Large bookcase (6-7 feet tall): |
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| Medium/Regular Bookcase: |
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| Small Bookcase (waist high): |
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| TV/ Stereo Stand: |
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| TV (under 25" screen): |
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| TV ( 25"- 36" screen): |
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| TV Big Screen (37"- 59" screen): |
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| TV Big Screen (60"- 72" Screen): |
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| Console TV/ Stereo (floor model): |
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| Projection TV: |
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| DVD/ VCR or Stereo Component (pieces): |
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| Dining Table: |
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| Dinette or Breakfast Table: |
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| Dining, Dinette or Breakfast Chairs: |
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| Kitchen Stools: |
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| Pantry Cabinet (usually in kitchen): |
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| China Cabinet (How many pieces?): |
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| Buffet, Server or Sideboard: |
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| Curio Cabinet: |
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| Baker's Rack: |
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| Double Door Refrigerator (must be empty, please have disconnected): |
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| Refrigerator or Upright Freezer (must be empty, please have disconnected): |
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| Chest Freezer (must be empty): |
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| Microwave or Cart: |
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| Washer or Dryer (count each one, please have disconnected): |
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| Stove, Oven or Range (please have disconnected): |
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| Ironing Board or Vacuum: |
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| Platform Bed or 4 Post Bed: |
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| Waterbed: |
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| King Mattress: |
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| Queen/Full/Double Mattress: |
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| Twin Mattress: |
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| Toddler Bed Set (including mattress): |
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| Crib or Cradle (including mattress): |
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| Large Headboard (2 men carry): |
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| Headboard (one man carry): |
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| Footboard: |
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| Metal Bed Frames (how many?): |
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| Armoire/Wardrobe: |
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| Chest of Drawers: |
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| Large Size Dresser: |
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| Small to Medium Size Dresser: |
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| Large Dresser or Wall Mirror: |
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| Small or Medium Dresser Mirror: |
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| Vanity: |
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| Nightstands: |
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| Cedar or Hope Chest: |
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| Cabinet Sewing Machine: |
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| Footlocker or Trunk: |
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| Changing Table: |
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| Infant Swing: |
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| Jewelry Chest: |
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| Suitcases: |
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| Hampers: |
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| Office Desk (list total pieces): |
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| Computer Desk: |
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| Executive Desk (large desk): |
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| Secretary Desk (tall cabinet pull-out desk): |
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| Small Desk (student/writing desk): |
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| Credenza: |
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| Office Chair: |
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| Storage Cabinet: |
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| 2-3 Drawer File Cabinet: |
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| 4-5 Drawer File Cabinet: |
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| Computer Components (how many pieces?): |
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| Printer Stand: |
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| Room Divider: |
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| Lb. Safe (list maximum weight): |
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| Folding Table: |
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| Folding Chairs (how many?): |
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| Patio or Picnic Table: |
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| Lg. Picnic Table (benches hooked on): |
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| Picnic Table Benches: |
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| Lawn/Patio Chair (how many?): |
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| Patio Umbrella: |
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Chaise Lounge: |
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| Bicycles: |
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| Outdoor Play House |
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| Grill/Smoker (must remove propane tank): |
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| Lawn Tractor (riding mower): |
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| Mower/Edger/Blower: |
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| Rakes/Shovels/etc.: |
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| Tool Chest: |
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| Work Bench: |
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| Utility/Metal Shelf: |
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| Step Ladders (under 10 feet): |
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| Extension Ladders: |
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| Garbage Can (no trash): |
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| Wheel Barrow: |
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| Small Boxes/Bags (can carry 3-4 at a time): |
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| Medium/Regular Boxes (2 per carry): |
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| Large Boxes (1 per carry): |
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| Play Pen: |
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| Toy Chest: |
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| Gallon Aquarium (total number of gallons, must be empty): |
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| Aquarium Stand: |
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| Floor Lamps (most other lamps need to be packed in boxes): |
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| Large Pictures (small pictures need to be packed in boxes): |
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| Baby Grand Piano: |
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| Upright Piano (chest/shoulder high): |
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| Spinet Piano (waist high or so): |
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| Organ: |
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| Piano/Organ Bench: |
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| Medium/Large Plants (we cannot move small plants): |
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| Area Rugs (up to 6'x8'): |
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| Medium/Large Rugs: |
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| Exercise Equipment (weight benches, exercise bike, stair stepper, treadmill, etc.): |
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| Pounds of Exercise Weights (total weight): |
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| Drum Sets: |
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| TV Dinner Trays (how many pieces?): |
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| If you are interested in AMSA's cleaning services please provide us with a little information. |
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| Would you like you carpet cleaned? |
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| How many bed rooms in your home? |
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| Would you like your home cleaned? |
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| If you require AMSA to do some packing, be aware that you will be charged by the hour for this service. You can provide your own materials or we can provide the materials at an additional cost to you. |
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| Do you need us to do some packing? |
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| If yes, how many hours do you think it will take for 2 men to get the job done? |
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| Additional Comments: |
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