Name:
Pick Up Address:
City
State
Zip
Phone
Delivery Address:
City
State
Zip
Phone:
Are there steps (1-3)?	yes no
Are there stairs (4 or more)?	yes no
Are we to set up the Furniture delivered/moved into your home?	yes no
Are you located in the Phoenix Metro area?	yes no
What kind of flooring is in your home? (please check all that apply)	Tile Carpet Flagstone Linoleum Hardwood Marble other:
Elevator?	yes no
Will the job demand 2 or 4 men?	2 4
Bedroom Items to be delivered? (please select number of items on each)	0 1 2 3 Armoire 0 1 2 3 Canopy Bed 0 1 2 3 Post Bed 0 1 2 3 Water Bed 0 1 2 3 King Bed 0 1 2 3 Queen Bed 0 1 2 3 Twin Bed 0 1 2 3 Night Stands 0 1 2 3 Dresser 0 1 2 3 Chest 0 1 2 3 Mirrors 0 1 2 3 Lamps
Dinning Room Items to be delivered? (please select number of items on each)	0 1 2 3 Buffet 0 1 2 3 China Cabinet 0 1 2 3 Dinning Table 0 1 2 3 4 5 6 7 8 Chairs
Kitchen Items to be delivered? (please select number of items on each)	0 1 2 3 Refrigerator 0 1 2 3 Bar Stools
Living Room Items to be delivered? (please select number of items on each)	0 1 2 3 Coffee Table 0 1 2 3 End Table 0 1 2 3 Ent. Center 0 1 2 3 Recliner 0 1 2 3 Sofa 0 1 2 3 Hide-A-Bed 0 1 2 3 TV Large 0 1 2 3 TV Small
Miscellaneous Items to be delivered? (please select number of items on each)	0 1 2 3 Desk 0 1 2 3 Grill 0 1 2 3 Shelves 0 1 2 3 File Cabinet 0 1 2 3 Pictures 0 1 2 3 Sml. Boxes 0 1 2 3 Lrg. Boxes
Comments: