What Service(s) Do You Need? (Check All That Apply) *
Date of Requested Service*
Will You Be In Need of Storage? If So, Please List Brief Description.*
V.C.A. Customer Business Name*
Customer’s Phone Number*
Customer’s Address of Service Origin*
Customer’s Address of Service Destination*
Address of Any Additional Stops (If Applicable): *
Estimated Miles Distance Between Destinations*
Type of Structure Service(s) at Origin*
List Any and All Items in Master Bedrooms That Will Be Moved:*
List Any and All Items in Bedroom 1*
List Any and All Items in Bedroom 2*
List Any and All Items in Bedroom 3*
List Any and All Items in Bedroom 4*
List Any and All Items in Bedroom 5 (Also If You Have More Than 5 Bedrooms, List Remaining Items)
List Any and All Items in Living/Family Rooms That Will Be Moved*
List Any and All Items in Dining Room/Den/Storage/Kitchen That Will Be Moved*
List Any and All Items in Garage/Guest Rooms That Will Be Moved*
Overall Square Feet of Structure at Origin*
Number of All Rooms at Origin: *
Features of Structure at Origin*
Please Describe Specifics of Stairs, Approaches, Landing, and Space at Loading Location *
Type of Structure at Destination*
Overall Square Feet of Structure at Destination*
Features of Structure at Destination*
Please Describe Specifics of Stairs, Approaches, Landing, and Space at Unloading Location *
Does Either Structure Have a Security Gate? If So, What Is the Security Code(s)? *
Estimated Number of Boxes
Estimated Number of Bags*
Estimated Number of Containers*
Level of Packing/Unpacking Needed*
Estimate Number of Large Items to Be Moved (Anything Larger Than a Night Stand)*
Estimated Number of Large Items That Are Greater Than 75 lbs*
Special Items Included in Service (Check All that Apply*
Please Describe Any Special Features or Notes of the Move (Safe, Piano, Appliance, etc. – Specifics)*
Any Items That You Are or Might Be Donating*
Level Assembly/Disassembly Needed*
What will be your Preferred Method of Payment (Check All that Apply)
