[one_half][text nam placeholder "Your Name"][/one_half] [one_half_last][tel tel placeholder "Contact Number"][/one_half_last]

[one_half][text date placeholder "Enter Date"][/one_half] [one_half_last][text time placeholder "Enter Time in AM / PM"][/one_half_last]

[one_third]Moving Information[/one_third] [one_half_last]  [/one_half_last]

[one_half][text mn placeholder "City Moving From"][/one_half] [one_half_last][text mb placeholder "City Moving To"][/one_half_last]

[one_third]Boxes[/one_third] [one_half_last]  [/one_half_last]

[one_third][checkbox Boxes1 "Book Box(Es)" "Large Box(Es)" "Picture(s)"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Boxes2 "Dish Pack" "Medium Box(Es)" "Mirror(s)"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Boxes3 "Extra Large Box(Es)" "Small Box(Es)" "Wardrobe Box(Es)"][/one_third][one_half_last]  [/one_half_last]

[one_third]Bedroom[/one_third] [one_half_last]  [/one_half_last]

[one_third][checkbox Bedroom1 "Armoire, Lrg" "Box, Wardrobe Lrg" "Dresser, Triple"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Bedroom2 "Armoire, Sm" "Box, Wardrobe Sm" "Dresser, Vanity"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Bedroom3 "Bed, Bunk (Set Of 2)" "Chair, Boudoir" "Dresser/Vanity Bench"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Bedroom4 "Bed, King" "Chair, Straight" "Floor Lamp/Table Lamp"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Bedroom5 "Bed, Queen" "Chaise Lounge" "Futon"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Bedroom6 "Bed, Rollaway" "Chest Of Drawers" "Night Table"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Bedroom7 "Bed, Single/Hollywood" "Chest, Armoire" "Sm / Winthrop Desk"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Bedroom8 "Bed, Std/Double/Full" "Chest, Bachelor/Cedar" "Student Desk"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Bedroom9 "Bed, Waterbed Base" "Daybed/Captains Bed" "Trunk"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Bedroom10 "Mattress King" "Mattress Queen" "Mattress Full”][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Bedroom11 "Mattress Single" "Box Spring Single" "Box Spring Queen"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Bedroom12 "Box Spring Full" "Temper Pedic Mattress" "Tv"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Bedroom13 "Night Stand" "Lamp Shade" "Pillows"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Bedroom14 "Bookcase" "Dresser, Double" "Wardrobe, Large"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Bedroom15 "Bookshelves Section" "Dresser, Single" "Wardrobe, Small"][/one_third][one_half_last]  [/one_half_last]


[one_third]Nursery[/one_third] [one_half_last]  [/one_half_last]

[one_third][checkbox Nursery1 "Baby Carriage" "Chair, Child. Reg & Rock" "Large, Rug"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Nursery2 "Baby Crib" "Chair, High" "Playpen"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Nursery3 "Bassinet" "Chest" "Rocking Chair"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Nursery4 "Bed, Youth" "Child Table" "Toy Chest"][/one_third][one_half_last]  [/one_half_last]


[one_third]Living Room[/one_third] [one_half_last]  [/one_half_last]

[one_third][checkbox Living1 "Bar, Portable" "Grandfather Clock" "Sectional Bookshelf"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Living2 "Bench Fireside" "Hall Tree, Large" "Sofa, 3 Cushion"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Living3 "Bookcase" "Hall Tree, Rack" "Sofa, 4 Cush Hideabed"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Living4 "Cedar Chest" "Lamp, Floor Or Pole" "Sofa, Loveseat"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Living5 "Chair, Arm" "Magazine Rack" "Sofa, Per Section"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Living6 "Chair, Occasional" "Music Cabinet" "Sofa, Rattan, Wicker"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Living7 "Chair, Overstuffed" "Ottoman" "Stereo Component"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Living8 "Chair, Rocker" "Phone Stand" "Stereo, Console"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Living9 "Chair, Straight" "Piano, Baby Grand" "Tables, Coffee"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Living10 "Chair, Wicker" "Piano, Bench" "Tables, Dropl/Occasional"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Living11 "Computer System" "Piano, Parlor Grand" "Tables, End"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Living12 "Curio Cabinet" "Piano, Spinet/Console" "Tv Stand"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Living13 "Day Bed" "Piano, Upright" "Tv, Big Screen"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Living14 "Desk, Secy" "Portable Record Player" "Tv, Combination"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Living15 "Desk, Sm. Winthrop" "Recliner" "Tv, Console"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Living16 "Entertainment Center" "Roll/Pad Rug, Large" "Tv, Portable"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Living17 "Fireplace Equipment" "Roll/Pad Rugs, Small" "Unit, Wall Lrg"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Living18 "Footstool" "Secretary Desk" "Unit, Wall Sm"][/one_third][one_half_last]  [/one_half_last]


[one_third]Dining Room[/one_third] [one_half_last]  [/one_half_last]

[one_third][checkbox Dining1 "Bakers Rack" "Dining Chair" "Rugs, Lg. Roll/Pad"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Dining2 "Base Buffet" "Dining Table" "Rugs, Sm. Roll/Pad"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Dining3 "Box, Dish Pack" "Harvest Bench" "Server"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Dining4 "China Cabinet" "Hutch" "Tea Cart"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Dining5 "Corner Cabinet" "Lamp"][/one_third][one_half_last]  [/one_half_last]


[one_third]Kitchen[/one_third] [one_half_last]  [/one_half_last]

[one_third][checkbox Kitchen1 "Baker's Rack" "Harvest Bench" "Stool"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Kitchen2 "Box, Dish-Pack" "Kitchen Cabinet" "Table"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Kitchen3 "Breadmaker" "Lamp" "Tea Cart"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Kitchen4 "Breakfast Suite, Chairs" "Microwave Oven" "Toaster Oven"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Kitchen5 "Breakfast Table" "Microwave Stand" "Utility Cabinet"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Kitchen6 "China Cabinet" "Serving Cart"][/one_third][one_half_last]  [/one_half_last]


[one_third]Appliances[/one_third] [one_half_last]  [/one_half_last]

[one_third][checkbox Appliances1 "Air Cond.-Window, Lrg" "Freezer 16 Or Over" "Refrig. 11 Cu. Ft. Or More"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Appliances2 "Air Cond.-Window, Sm" "Range, 20'' Wide" "Shopvac"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Appliances3 "Dehumidifier" "Range, 30'' Wide" "Stackable Washer/Dryer"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Appliances4 "Dishwasher" "Range, 36'' Wide" "Trash Compactor"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Appliances5 "Dryer" "Refrig. 6 Cu. Ft. Or Less" "Vacuum Cleaner"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Appliances6 "Freezer 10 Or Less" "Refrig. 7 To 10 Cu.Ft." "Washing Machine"][/one_third][one_half_last]  [/one_half_last]


[one_third]Porch/ Outdoor/ Patio[/one_third] [one_half_last]  [/one_half_last]

[one_third][checkbox Porch1 "Bbq Grill Large" "Ladder, Extension" "Picnic Bench"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Porch2 "Bbq Grill Medium" "Lawn Mower, Hand" "Picnic Table"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Porch3 "Bbq Grill Small" "Lawn Mower, Power" "Sand Box"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Porch4 "Birdbath" "Lawn Mower, Riding (Hp)" "Spreader"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Porch5 "Chairs, Aluminum" "Lawn Roller" "Swing Set"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Porch6 "Chairs, Metal" "Lawn Statue" "Trampoline"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Porch7 "Chairs, Wood" "Leaf Blower" "Table, Large"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Porch8 "Garden Hose & Tools" "Outdoor Child Gym" "Table, Small"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Porch9 "Glider Or Settee" "Outdoor Child Slide" "Umbrella"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Porch10 "Ladder, 6' Step" "Outdoor Dry Racks" "Wheelbarrow"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Porch11 "Ladder, 8' Metal" "Outdoor Swings"][/one_third][one_half_last]  [/one_half_last]


[one_third]Rec. Room/ Garage/ Office[/one_third] [one_half_last]  [/one_half_last]


[one_third][checkbox Rec1 "Baby Carriage" "Filing Cab. 3 Drawers" "Sewing Mach. W/Cabinet"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Rec2 "Barbells" "Filing Cab. 4 Drawers" "Sled"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Rec3 "Bicycle" "Filing Cabinet Cardboard" "Suitcase"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Rec4 "Bowling Ball/Bag" "Folding Chairs" "Table, Game"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Rec5 "Box, Book" "Folding Cot" "Table, Ping Pong"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Rec6 "Box, Large" "Footlockers" "Tackle Box"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Rec7 "Box, Medium" "Gas/Electric Heater" "Tire"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Rec8 "Grand Piano" "Baby Grand Piano" "Upright Piano"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Rec9 "Electric Piano" "Digital Piano" "Golf Kit"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Rec10 "Box, Small" "Golf Bag" "Tire With Rim"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Rec11 "Card Table" "Hot Tub" "Toolchest, Large"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Rec12 "Child's Wagon" "Metal Shelves" "Toolchest, Medium"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Rec13 "Clothes Basket" "Office Desk" "Toolchest, Small"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Rec14 "Clothes Hamper" "Pool Table Comp." "Trampoline"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Rec15 "Cot, Folding" "Pool Table Stand" "Trash Can"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Rec16 "Exercycle" "Power Tool Hand" "Tricycle"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Rec17 "Exercise Machine" "Power Tool Stand" "Utility Table"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Rec18 "Fan" "Rug, Large" "Wastepaper Basket" "Fern/Plants Stands"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Rec19 "Sewing Machine Console" "Work Bench" "Filing Cab. 2 Drawers"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Rec20 "Sewing Machine Portable" "Guitar" "Paintings"][/one_third][one_half_last]  [/one_half_last]


[one_third]Electronics[/one_third] [one_half_last]  [/one_half_last]

[one_third][checkbox Electronics1 "Tv 80 Series" "Computer Desk" "Office Copier"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Electronics2 "Tv 70 Series" "Computer Flat Screen" "Pc/Computer"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Electronics3 "Tv 60 Series" "Computer Monitor/Screen" "Satellite, Lg"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Electronics4 "Tv 50 Series" "Computer Printer" "Satellite, Sm"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Electronics5 "Tv 40 Series" "Tv Stand" "Tower Speakers"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Electronics6 "Tv 30 Series" "Blue Ray" "Home Theatre"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Electronics7 "Tv, Portable 13&quot;-15&quot;" "Dvd Player" "Scanner"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Electronics8 "Entertainment Center" "Shelf Speaker" "Typewriter, Portable"][/one_third][one_half_last]  [/one_half_last]
[one_third][checkbox Electronics9 "Fax Machine" "Stereo Component" "Vcrs" "Floor Speaker"][/one_third][one_half_last]  [/one_half_last]


[one_third]Totals[/one_third] [one_half_last]  [/one_half_last]

[one_half][text t1 placeholder "Cubic Foot Volume"][/one_half] [one_half_last][text t2 placeholder "Estimated Weight"][/one_half_last]

[one_half][text textarea-6 placeholder "Additional Comments"][/one_half] [one_half_last] [/one_half_last]

[submit "Submit"]