[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 Boxes "Book Box(Es)" "Large Box(Es)" "Picture(s)"][/one_third][one_half_last]  [/one_half_last]

[one_third][checkbox Boxess "Dish Pack" "Medium Box(Es)" "Mirror(s)"][/one_third][one_half_last]  [/one_half_last]

[one_third_last][checkbox Boxesss "Extra Large Box(Es)" "Small Box(Es)" "Wardrobe Box(Es)"][/one_third_last][one_half_last]  [/one_half_last]

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

[one_third][checkbox* bedroomnn "Armoire, Lrg" "Box, Wardrobe Lrg" "Dresser, Triple" "Armoire, Sm" "Box, Wardrobe Sm" "Dresser, Vanity" "Bed, Bunk (Set Of 2)" "Chair, Boudoir" "Dresser/Vanity Bench" "Bed, King" "Chair, Straight" "Floor Lamp/Table Lamp" "Bed, Queen" "Chaise Lounge" "Futon"][/one_third] [one_third][checkbox* Bedroomq "Bed, Rollaway" "Chest Of Drawers" "Night Table" "Bed, Single/Hollywood" "Chest, Armoire" "Sm / Winthrop Desk" "Bed, Std/Double/Full" "Chest, Bachelor/Cedar" "Student Desk" "Bed, Waterbed Base" "Daybed/Captains Bed" "Trunk" "Mattress King" "Mattress Queen" "Mattress Full"][/one_third] [one_third_last][checkbox* Bedroomw "Mattress Single" "Box Spring Single" "Box Spring Queen" "Box Spring Full" "Temper Pedic Mattress" "Tv" "Night Stand" "Lamp Shade" "Pillows" "Bookcase" "Dresser, Double" "Wardrobe, Large" "Bookshelves Section" "Dresser, Single" "Wardrobe, Small"][/one_third_last]

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

[one_third][checkbox* Nursery "Baby Carriage" "Chair, Child. Reg & Rock" "Large, Rug" "Baby Crib"][/one_third] [one_third][checkbox* Nurserye "Chair, High" "Playpen" "Bassinet" "Chest"][/one_third] [one_third_last][checkbox* Nurseryc "Rocking Chair" "Bed, Youth" "Child Table" "Toy Chest"][/one_third_last]

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

[one_third][checkbox* LivingRoom "Bar, Portable" "Grandfather Clock" "Sectional Bookshelf" "Bench Fireside" "Hall Tree, Large" "Sofa, 3 Cushion" "Bookcase" "Hall Tree, Rack" "Sofa, 4 Cush Hideabed" "Cedar Chest" "Lamp, Floor Or Pole" "Sofa, Loveseat" "Chair, Arm" "Magazine Rack" "Sofa, Per Section" "Chair, Occasional" "Music Cabinet" "Sofa, Rattan, Wicker"][/one_third] [one_third][checkbox* LivingRoome "Chair, Overstuffed" "Ottoman" "Stereo Component" "Chair, Rocker" "Phone Stand" "Stereo, Console" "Chair, Straight" "Piano, Baby Grand" "Tables, Coffee" "Chair, Wicker" "Piano, Bench" "Tables, Dropl/Occasional" "Computer System" "Piano, Parlor Grand" "Tables, End" "Curio Cabinet" "Piano, Spinet/Console" "Tv Stand"][/one_third] [one_third_last][checkbox* LivingRoomc "Day Bed" "Piano, Upright" "Tv, Big Screen" "Desk, Secy" "Portable Record Player" "Tv, Combination" "Desk, Sm. Winthrop" "Recliner" "Tv, Console" "Entertainment Center" "Roll/Pad Rug, Large" "Tv, Portable" "Fireplace Equipment" "Roll/Pad Rugs, Small" "Unit, Wall Lrg" "Footstool" "Secretary Desk" "Unit, Wall Sm"][/one_third_last]

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

[one_third][checkbox* DiningRoom "Bakers Rack" "Dining Chair" "Rugs, Lg. Roll/Pad" "Base Buffet" "Dining Table"][/one_third] [one_third][checkbox* DiningRoomn "Rugs, Sm. Roll/Pad" "Box, Dish Pack" "Harvest Bench" "Server" "China Cabinet"][/one_third] [one_third_last][checkbox* DiningRoomc "Hutch" "Tea Cart" "Corner Cabinet" "Lamp"][/one_third_last]

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

[one_third][checkbox* Kitchen "Baker's Rack" "Harvest Bench" "Stool" "Box, Dish-Pack" "Kitchen Cabinet" "Table"][/one_third] [one_third][checkbox* Kitchenb "Breadmaker" "Lamp" "Tea Cart" "Breakfast Suite, Chairs" "Microwave Oven" "Toaster Oven"][/one_third] [one_third_last][checkbox* Kitchenc "Breakfast Table" "Microwave Stand" "Utility Cabinet" "China Cabinet" "Serving Cart"][/one_third_last]

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

[one_third][checkbox* Appliances "Air Cond.-Window, Lrg" "Freezer 16 Or Over" "Refrig. 11 Cu. Ft. Or More" "Air Cond.-Window, Sm" "Range, 20'' Wide" "Shopvac" "Dehumidifier"][/one_third] [one_third][checkbox* Appliancesg "Range, 30'' Wide" "Stackable Washer/Dryer" "Dishwasher" "Range, 36'' Wide" "Trash Compactor" "Dryer" "Refrig. 6 Cu. Ft. Or Less"][/one_third] [one_third_last][checkbox* Appliancesb "Vacuum Cleaner" "Freezer 10 Or Less" "Refrig. 7 To 10 Cu.Ft." "Washing Machine" "Freezer 11 Or 15"][/one_third_last]

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

[one_third][checkbox* PorchOutdoorPatio "Bbq Grill Large" "Ladder, Extension" "Picnic Bench" "Bbq Grill Medium" "Lawn Mower, Hand" "Picnic Table" "Bbq Grill Small" "Lawn Mower, Power" "Sand Box" "Birdbath" "Lawn Mower, Riding (Hp)"][/one_third] [one_third][checkbox* PorchOutdoorPatiog "Spreader" "Chairs, Aluminum" "Lawn Roller" "Swing Set" "Chairs, Metal" "Lawn Statue" "Trampoline" "Chairs, Wood" "Leaf Blower" "Table, Large" "Garden Hose & Tools"][/one_third] [one_third_last][checkbox* PorchOutdoorPatioh "Outdoor Child Gym" "Table, Small" "Glider Or Settee" "Outdoor Child Slide" "Umbrella" "Ladder, 6' Step" "Outdoor Dry Racks" "Wheelbarrow" "Ladder, 8' Metal" "Outdoor Swings"][/one_third_last]

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


[one_third][checkbox* Rec.RoomGarageOffice "Baby Carriage" "Filing Cab. 3 Drawers" "Sewing Mach. W/Cabinet" "Barbells" "Filing Cab. 4 Drawers" "Sled" "Bicycle" "Filing Cabinet Cardboard" "Suitcase" "Bowling Ball/Bag" "Folding Chairs" "Table, Game" "Box, Book" "Folding Cot" "Table, Ping Pong" "Box, Large" "Footlockers" "Tackle Box" "Box, Medium" "Gas/Electric Heater" "Tire"][/one_third] [one_third][checkbox* Rec.RoomGarageOfficec "Grand Piano" "Baby Grand Piano" "Upright Piano" "Electric Piano" "Digital Piano" "Golf Kit" "Box, Small" "Golf Bag" "Tire With Rim" "Card Table" "Hot Tub" "Toolchest, Large" "Child's Wagon" "Metal Shelves" "Toolchest, Medium" "Clothes Basket" "Office Desk" "Toolchest, Small" "Clothes Hamper" "Pool Table Comp." "Trampoline"][/one_third] [one_third_last][checkbox* Rec.RoomGarageOfficev "Cot, Folding" "Pool Table Stand" "Trash Can" "Exercycle" "Power Tool Hand" "Tricycle" "Exercise Machine" "Power Tool Stand" "Utility Table" "Fan" "Rug, Large" "Wastepaper Basket" "Fern/Plants Stands" "Sewing Machine Console" "Work Bench" "Filing Cab. 2 Drawers" "Sewing Machine Portable" "Guitar" "Paintings"][/one_third_last]

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

[one_third][checkbox* Electronics "Tv 80 Series" "Computer Desk" "Office Copier" "Tv 70 Series" "Computer Flat Screen" "Pc/Computer" "Tv 60 Series" "Computer Monitor/Screen" "Satellite, Lg" "Tv 50 Series"][/one_third] [one_third][checkbox* Electronicsv "Computer Printer" "Satellite, Sm" "Tv 40 Series" "Tv Stand" "Tower Speakers" "Tv 30 Series" "Blue Ray" "Home Theatre" "Tv, Portable 13&quot;-15&quot;" "Dvd Player"][/one_third] [one_third_last][checkbox* Electronicsx "Scanner" "Entertainment Center" "Shelf Speaker" "Typewriter, Portable" "Fax Machine" "Stereo Component" "Vcrs" "Floor Speaker"][/one_third_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"]