Bill To Mover    C.O.D. to Shipper    C.O.D. Rate Mover: 
Sent by:  Phone Number:   E-mail Address: 
P.O./Order#:  Origin     Destination
Pack Date:        Load Date:        Delivery Date: 
Customer:  Service Date: 
Origin Address:   Destination Address: 
City:    State:    Zip:  City:    State:    Zip: 
Origin Phone:  Destination Phone: 
Origin Work:  Destination Work:  
Cell Phone 1:      Cell Phone 2:      Alternate #: 
CRATES  
Item 1:   Size:  Item 6:     Size: 
Item 2:   Size:  Item 7:     Size: 
Item 3:   Size:  Item 8:     Size: 
Item 4:   Size:  Item 9:     Size: 
Item 5:   Size:  Item 10:   Size: 
Crates must be stamped for Export:   Yes     No
Washer:        Top Loading     Front Loading F/L Kit Authorized: Yes     No
Dryer:           Electric     Gas Special Instructions:
Icemaker:     Waterline Auth (Dest)   Yes     No
Grandfather Clock:      Yes    No    Service
Bed - Type:
Chandelier:        Yes     No
Ceiling Fan:       Yes     No
Wall Unit/Shrank - Describe:
TV Type:  :   / Size:   inch      Crate        Uncrate
TV Type:  :   / Size:   inch      Crate        Uncrate
Piano:          Lock Keys       Unlock keys        Assemble        Disassemble       Crate        Uncrate
Pool Table:   Assemble        Disassemble       Crate        Uncrate
:  Metal     Wood     Model:
Exercise Equipment: Make/Model: