*Last Name:                                      *First Name:
                   

  Street Address:            City:                            State:      
     Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  Zip Code:

  *Daytime Phone:                Evening Phone:
         

  Moving To?(City):                              State:
                          Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

When will your move happen?
             1-2 months        3-6 months        6-12 months

Weight of shipment in pounds:
             1,000 - 2,000 (1 bedroom)
             2,001 - 4,000 (2 bedroom)
             4,001 - 8,000 (3 bedroom)
             8,001 - 12,000 (4 bedroom)
             12,000 and over

Will you need boxes?
             Yes              No

Would you like us to perform packing services?
             Yes (Full Pack)
             Yes (Partial Pack)
             No

Would you like us to unpack in your new residence?
             Yes              No

Do you need Temporary Storage?
             Yes              No

(If Temporary Storage is needed)
How long would you need storage for?
             1 Month
             2 Months
             3 Months
             Longer?

Would you like us to move your automobile?
             Yes              No

Do you have stairs at your "Present" Location?
             Yes              No

Do you have stairs at your "New" Location?
             Yes              No

Is there an elevator at your "Present" Location?
             Yes              No

Is there an elevator at your "New" Location?
             Yes              No

Are you a member of AAA?
             Yes              No

Where did you hear about us? (Plaese check all that apply)
    Direct Mail     Yellow Pages    AAA World
     AAA South Jersey                       Internet
    Referral         Other


  Other Instructions, or Comments (Not required)