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Name

Address

Phone

Email Address

Where are you moving to?

Do you need storage services? Do you need storage services? Yes No

Are you packing your belongings yourself? Are you packing your belongings yourself? Yes No

Boxes or Totes Boxes or TotesBoxesTotes

# of Bed Frames # of Bed Frames123456 or more

# of Mattresses # of Mattresses123456 or more

# of Dressers # of Dressers123456 or more

# of Tables # of Tables123456 or more

# of Chairs

Do you need your dishes packed for you? Do you need your dishes packed for you? Yes No

# of sofa cushions # of sofa cushions1234567891011 or more

Love Seat Love Seat Yes No

Ottoman Ottoman Yes No

Bookshelf Bookshelf Yes No

Entertainment Center Entertainment Center Yes No

# of Picture Frames / Mirrors # of Picture Frames / Mirrors12345678910 to 1515 to 2020 or more

# of Televisions # of Televisions1234567 or more