<h2>Survey Online</h2>		
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<p>[one_half]<input type="text" name="nam" value="" size="40" aria-invalid="false" placeholder="Your Name" />[/one_half] [one_half_last]<input type="tel" name="tel" value="" size="40" aria-invalid="false" placeholder="Contact Number" />[/one_half_last]</p>
<p>[one_half]<input type="text" name="date" value="" size="40" aria-invalid="false" placeholder="Enter Date" />[/one_half] [one_half_last]<input type="text" name="time" value="" size="40" aria-invalid="false" placeholder="Enter Time in AM / PM" />[/one_half_last]</p>
<p>[one_third]Moving Information[/one_third] [one_half_last]  [/one_half_last]</p>
<p>[one_half]<input type="text" name="mn" value="" size="40" aria-invalid="false" placeholder="City Moving From" />[/one_half] [one_half_last]<input type="text" name="mb" value="" size="40" aria-invalid="false" placeholder="City Moving To" />[/one_half_last]</p>
<p>[one_third]Boxes[/one_third] [one_half_last]  [/one_half_last]</p>
<p>[one_third]<input type="checkbox" name="Boxes1[]" value="Book Box(Es)" />Book Box(Es)<input type="checkbox" name="Boxes1[]" value="Large Box(Es)" />Large Box(Es)<input type="checkbox" name="Boxes1[]" value="Picture(s)" />Picture(s)[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Boxes2[]" value="Dish Pack" />Dish Pack<input type="checkbox" name="Boxes2[]" value="Medium Box(Es)" />Medium Box(Es)<input type="checkbox" name="Boxes2[]" value="Mirror(s)" />Mirror(s)[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Boxes3[]" value="Extra Large Box(Es)" />Extra Large Box(Es)<input type="checkbox" name="Boxes3[]" value="Small Box(Es)" />Small Box(Es)<input type="checkbox" name="Boxes3[]" value="Wardrobe Box(Es)" />Wardrobe Box(Es)[/one_third][one_half_last]  [/one_half_last]</p>
<p>[one_third]Bedroom[/one_third] [one_half_last]  [/one_half_last]</p>
<p>[one_third]<input type="checkbox" name="Bedroom1[]" value="Armoire, Lrg" />Armoire, Lrg<input type="checkbox" name="Bedroom1[]" value="Box, Wardrobe Lrg" />Box, Wardrobe Lrg<input type="checkbox" name="Bedroom1[]" value="Dresser, Triple" />Dresser, Triple[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Bedroom2[]" value="Armoire, Sm" />Armoire, Sm<input type="checkbox" name="Bedroom2[]" value="Box, Wardrobe Sm" />Box, Wardrobe Sm<input type="checkbox" name="Bedroom2[]" value="Dresser, Vanity" />Dresser, Vanity[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Bedroom3[]" value="Bed, Bunk (Set Of 2)" />Bed, Bunk (Set Of 2)<input type="checkbox" name="Bedroom3[]" value="Chair, Boudoir" />Chair, Boudoir<input type="checkbox" name="Bedroom3[]" value="Dresser/Vanity Bench" />Dresser/Vanity Bench[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Bedroom4[]" value="Bed, King" />Bed, King<input type="checkbox" name="Bedroom4[]" value="Chair, Straight" />Chair, Straight<input type="checkbox" name="Bedroom4[]" value="Floor Lamp/Table Lamp" />Floor Lamp/Table Lamp[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Bedroom5[]" value="Bed, Queen" />Bed, Queen<input type="checkbox" name="Bedroom5[]" value="Chaise Lounge" />Chaise Lounge<input type="checkbox" name="Bedroom5[]" value="Futon" />Futon[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Bedroom6[]" value="Bed, Rollaway" />Bed, Rollaway<input type="checkbox" name="Bedroom6[]" value="Chest Of Drawers" />Chest Of Drawers<input type="checkbox" name="Bedroom6[]" value="Night Table" />Night Table[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Bedroom7[]" value="Bed, Single/Hollywood" />Bed, Single/Hollywood<input type="checkbox" name="Bedroom7[]" value="Chest, Armoire" />Chest, Armoire<input type="checkbox" name="Bedroom7[]" value="Sm / Winthrop Desk" />Sm / Winthrop Desk[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Bedroom8[]" value="Bed, Std/Double/Full" />Bed, Std/Double/Full<input type="checkbox" name="Bedroom8[]" value="Chest, Bachelor/Cedar" />Chest, Bachelor/Cedar<input type="checkbox" name="Bedroom8[]" value="Student Desk" />Student Desk[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Bedroom9[]" value="Bed, Waterbed Base" />Bed, Waterbed Base<input type="checkbox" name="Bedroom9[]" value="Daybed/Captains Bed" />Daybed/Captains Bed<input type="checkbox" name="Bedroom9[]" value="Trunk" />Trunk[/one_third][one_half_last]  [/one_half_last]<br />
[one_third][/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Bedroom11[]" value="Mattress Single" />Mattress Single<input type="checkbox" name="Bedroom11[]" value="Box Spring Single" />Box Spring Single<input type="checkbox" name="Bedroom11[]" value="Box Spring Queen" />Box Spring Queen[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Bedroom12[]" value="Box Spring Full" />Box Spring Full<input type="checkbox" name="Bedroom12[]" value="Temper Pedic Mattress" />Temper Pedic Mattress<input type="checkbox" name="Bedroom12[]" value="Tv" />Tv[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Bedroom13[]" value="Night Stand" />Night Stand<input type="checkbox" name="Bedroom13[]" value="Lamp Shade" />Lamp Shade<input type="checkbox" name="Bedroom13[]" value="Pillows" />Pillows[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Bedroom14[]" value="Bookcase" />Bookcase<input type="checkbox" name="Bedroom14[]" value="Dresser, Double" />Dresser, Double<input type="checkbox" name="Bedroom14[]" value="Wardrobe, Large" />Wardrobe, Large[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Bedroom15[]" value="Bookshelves Section" />Bookshelves Section<input type="checkbox" name="Bedroom15[]" value="Dresser, Single" />Dresser, Single<input type="checkbox" name="Bedroom15[]" value="Wardrobe, Small" />Wardrobe, Small[/one_third][one_half_last]  [/one_half_last]</p>
<p>[one_third]Nursery[/one_third] [one_half_last]  [/one_half_last]</p>
<p>[one_third]<input type="checkbox" name="Nursery1[]" value="Baby Carriage" />Baby Carriage<input type="checkbox" name="Nursery1[]" value="Chair, Child. Reg &amp; Rock" />Chair, Child. Reg &amp; Rock<input type="checkbox" name="Nursery1[]" value="Large, Rug" />Large, Rug[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Nursery2[]" value="Baby Crib" />Baby Crib<input type="checkbox" name="Nursery2[]" value="Chair, High" />Chair, High<input type="checkbox" name="Nursery2[]" value="Playpen" />Playpen[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Nursery3[]" value="Bassinet" />Bassinet<input type="checkbox" name="Nursery3[]" value="Chest" />Chest<input type="checkbox" name="Nursery3[]" value="Rocking Chair" />Rocking Chair[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Nursery4[]" value="Bed, Youth" />Bed, Youth<input type="checkbox" name="Nursery4[]" value="Child Table" />Child Table<input type="checkbox" name="Nursery4[]" value="Toy Chest" />Toy Chest[/one_third][one_half_last]  [/one_half_last]</p>
<p>[one_third]Living Room[/one_third] [one_half_last]  [/one_half_last]</p>
<p>[one_third]<input type="checkbox" name="Living1[]" value="Bar, Portable" />Bar, Portable<input type="checkbox" name="Living1[]" value="Grandfather Clock" />Grandfather Clock<input type="checkbox" name="Living1[]" value="Sectional Bookshelf" />Sectional Bookshelf[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Living2[]" value="Bench Fireside" />Bench Fireside<input type="checkbox" name="Living2[]" value="Hall Tree, Large" />Hall Tree, Large<input type="checkbox" name="Living2[]" value="Sofa, 3 Cushion" />Sofa, 3 Cushion[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Living3[]" value="Bookcase" />Bookcase<input type="checkbox" name="Living3[]" value="Hall Tree, Rack" />Hall Tree, Rack<input type="checkbox" name="Living3[]" value="Sofa, 4 Cush Hideabed" />Sofa, 4 Cush Hideabed[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Living4[]" value="Cedar Chest" />Cedar Chest<input type="checkbox" name="Living4[]" value="Lamp, Floor Or Pole" />Lamp, Floor Or Pole<input type="checkbox" name="Living4[]" value="Sofa, Loveseat" />Sofa, Loveseat[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Living5[]" value="Chair, Arm" />Chair, Arm<input type="checkbox" name="Living5[]" value="Magazine Rack" />Magazine Rack<input type="checkbox" name="Living5[]" value="Sofa, Per Section" />Sofa, Per Section[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Living6[]" value="Chair, Occasional" />Chair, Occasional<input type="checkbox" name="Living6[]" value="Music Cabinet" />Music Cabinet<input type="checkbox" name="Living6[]" value="Sofa, Rattan, Wicker" />Sofa, Rattan, Wicker[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Living7[]" value="Chair, Overstuffed" />Chair, Overstuffed<input type="checkbox" name="Living7[]" value="Ottoman" />Ottoman<input type="checkbox" name="Living7[]" value="Stereo Component" />Stereo Component[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Living8[]" value="Chair, Rocker" />Chair, Rocker<input type="checkbox" name="Living8[]" value="Phone Stand" />Phone Stand<input type="checkbox" name="Living8[]" value="Stereo, Console" />Stereo, Console[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Living9[]" value="Chair, Straight" />Chair, Straight<input type="checkbox" name="Living9[]" value="Piano, Baby Grand" />Piano, Baby Grand<input type="checkbox" name="Living9[]" value="Tables, Coffee" />Tables, Coffee[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Living10[]" value="Chair, Wicker" />Chair, Wicker<input type="checkbox" name="Living10[]" value="Piano, Bench" />Piano, Bench<input type="checkbox" name="Living10[]" value="Tables, Dropl/Occasional" />Tables, Dropl/Occasional[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Living11[]" value="Computer System" />Computer System<input type="checkbox" name="Living11[]" value="Piano, Parlor Grand" />Piano, Parlor Grand<input type="checkbox" name="Living11[]" value="Tables, End" />Tables, End[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Living12[]" value="Curio Cabinet" />Curio Cabinet<input type="checkbox" name="Living12[]" value="Piano, Spinet/Console" />Piano, Spinet/Console<input type="checkbox" name="Living12[]" value="Tv Stand" />Tv Stand[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Living13[]" value="Day Bed" />Day Bed<input type="checkbox" name="Living13[]" value="Piano, Upright" />Piano, Upright<input type="checkbox" name="Living13[]" value="Tv, Big Screen" />Tv, Big Screen[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Living14[]" value="Desk, Secy" />Desk, Secy<input type="checkbox" name="Living14[]" value="Portable Record Player" />Portable Record Player<input type="checkbox" name="Living14[]" value="Tv, Combination" />Tv, Combination[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Living15[]" value="Desk, Sm. Winthrop" />Desk, Sm. Winthrop<input type="checkbox" name="Living15[]" value="Recliner" />Recliner<input type="checkbox" name="Living15[]" value="Tv, Console" />Tv, Console[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Living16[]" value="Entertainment Center" />Entertainment Center<input type="checkbox" name="Living16[]" value="Roll/Pad Rug, Large" />Roll/Pad Rug, Large<input type="checkbox" name="Living16[]" value="Tv, Portable" />Tv, Portable[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Living17[]" value="Fireplace Equipment" />Fireplace Equipment<input type="checkbox" name="Living17[]" value="Roll/Pad Rugs, Small" />Roll/Pad Rugs, Small<input type="checkbox" name="Living17[]" value="Unit, Wall Lrg" />Unit, Wall Lrg[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Living18[]" value="Footstool" />Footstool<input type="checkbox" name="Living18[]" value="Secretary Desk" />Secretary Desk<input type="checkbox" name="Living18[]" value="Unit, Wall Sm" />Unit, Wall Sm[/one_third][one_half_last]  [/one_half_last]</p>
<p>[one_third]Dining Room[/one_third] [one_half_last]  [/one_half_last]</p>
<p>[one_third]<input type="checkbox" name="Dining1[]" value="Bakers Rack" />Bakers Rack<input type="checkbox" name="Dining1[]" value="Dining Chair" />Dining Chair<input type="checkbox" name="Dining1[]" value="Rugs, Lg. Roll/Pad" />Rugs, Lg. Roll/Pad[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Dining2[]" value="Base Buffet" />Base Buffet<input type="checkbox" name="Dining2[]" value="Dining Table" />Dining Table<input type="checkbox" name="Dining2[]" value="Rugs, Sm. Roll/Pad" />Rugs, Sm. Roll/Pad[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Dining3[]" value="Box, Dish Pack" />Box, Dish Pack<input type="checkbox" name="Dining3[]" value="Harvest Bench" />Harvest Bench<input type="checkbox" name="Dining3[]" value="Server" />Server[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Dining4[]" value="China Cabinet" />China Cabinet<input type="checkbox" name="Dining4[]" value="Hutch" />Hutch<input type="checkbox" name="Dining4[]" value="Tea Cart" />Tea Cart[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Dining5[]" value="Corner Cabinet" />Corner Cabinet<input type="checkbox" name="Dining5[]" value="Lamp" />Lamp[/one_third][one_half_last]  [/one_half_last]</p>
<p>[one_third]Kitchen[/one_third] [one_half_last]  [/one_half_last]</p>
<p>[one_third]<input type="checkbox" name="Kitchen1[]" value="Baker&#039;s Rack" />Baker&#039;s Rack<input type="checkbox" name="Kitchen1[]" value="Harvest Bench" />Harvest Bench<input type="checkbox" name="Kitchen1[]" value="Stool" />Stool[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Kitchen2[]" value="Box, Dish-Pack" />Box, Dish-Pack<input type="checkbox" name="Kitchen2[]" value="Kitchen Cabinet" />Kitchen Cabinet<input type="checkbox" name="Kitchen2[]" value="Table" />Table[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Kitchen3[]" value="Breadmaker" />Breadmaker<input type="checkbox" name="Kitchen3[]" value="Lamp" />Lamp<input type="checkbox" name="Kitchen3[]" value="Tea Cart" />Tea Cart[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Kitchen4[]" value="Breakfast Suite, Chairs" />Breakfast Suite, Chairs<input type="checkbox" name="Kitchen4[]" value="Microwave Oven" />Microwave Oven<input type="checkbox" name="Kitchen4[]" value="Toaster Oven" />Toaster Oven[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Kitchen5[]" value="Breakfast Table" />Breakfast Table<input type="checkbox" name="Kitchen5[]" value="Microwave Stand" />Microwave Stand<input type="checkbox" name="Kitchen5[]" value="Utility Cabinet" />Utility Cabinet[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Kitchen6[]" value="China Cabinet" />China Cabinet<input type="checkbox" name="Kitchen6[]" value="Serving Cart" />Serving Cart[/one_third][one_half_last]  [/one_half_last]</p>
<p>[one_third]Appliances[/one_third] [one_half_last]  [/one_half_last]</p>
<p>[one_third]<input type="checkbox" name="Appliances1[]" value="Air Cond.-Window, Lrg" />Air Cond.-Window, Lrg<input type="checkbox" name="Appliances1[]" value="Freezer 16 Or Over" />Freezer 16 Or Over<input type="checkbox" name="Appliances1[]" value="Refrig. 11 Cu. Ft. Or More" />Refrig. 11 Cu. Ft. Or More[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Appliances2[]" value="Air Cond.-Window, Sm" />Air Cond.-Window, Sm<input type="checkbox" name="Appliances2[]" value="Range, 20&#039;&#039; Wide" />Range, 20&#039;&#039; Wide<input type="checkbox" name="Appliances2[]" value="Shopvac" />Shopvac[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Appliances3[]" value="Dehumidifier" />Dehumidifier<input type="checkbox" name="Appliances3[]" value="Range, 30&#039;&#039; Wide" />Range, 30&#039;&#039; Wide<input type="checkbox" name="Appliances3[]" value="Stackable Washer/Dryer" />Stackable Washer/Dryer[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Appliances4[]" value="Dishwasher" />Dishwasher<input type="checkbox" name="Appliances4[]" value="Range, 36&#039;&#039; Wide" />Range, 36&#039;&#039; Wide<input type="checkbox" name="Appliances4[]" value="Trash Compactor" />Trash Compactor[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Appliances5[]" value="Dryer" />Dryer<input type="checkbox" name="Appliances5[]" value="Refrig. 6 Cu. Ft. Or Less" />Refrig. 6 Cu. Ft. Or Less<input type="checkbox" name="Appliances5[]" value="Vacuum Cleaner" />Vacuum Cleaner[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Appliances6[]" value="Freezer 10 Or Less" />Freezer 10 Or Less<input type="checkbox" name="Appliances6[]" value="Refrig. 7 To 10 Cu.Ft." />Refrig. 7 To 10 Cu.Ft.<input type="checkbox" name="Appliances6[]" value="Washing Machine" />Washing Machine[/one_third][one_half_last]  [/one_half_last]</p>
<p>[one_third]Porch/ Outdoor/ Patio[/one_third] [one_half_last]  [/one_half_last]</p>
<p>[one_third]<input type="checkbox" name="Porch1[]" value="Bbq Grill Large" />Bbq Grill Large<input type="checkbox" name="Porch1[]" value="Ladder, Extension" />Ladder, Extension<input type="checkbox" name="Porch1[]" value="Picnic Bench" />Picnic Bench[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Porch2[]" value="Bbq Grill Medium" />Bbq Grill Medium<input type="checkbox" name="Porch2[]" value="Lawn Mower, Hand" />Lawn Mower, Hand<input type="checkbox" name="Porch2[]" value="Picnic Table" />Picnic Table[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Porch3[]" value="Bbq Grill Small" />Bbq Grill Small<input type="checkbox" name="Porch3[]" value="Lawn Mower, Power" />Lawn Mower, Power<input type="checkbox" name="Porch3[]" value="Sand Box" />Sand Box[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Porch4[]" value="Birdbath" />Birdbath<input type="checkbox" name="Porch4[]" value="Lawn Mower, Riding (Hp)" />Lawn Mower, Riding (Hp)<input type="checkbox" name="Porch4[]" value="Spreader" />Spreader[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Porch5[]" value="Chairs, Aluminum" />Chairs, Aluminum<input type="checkbox" name="Porch5[]" value="Lawn Roller" />Lawn Roller<input type="checkbox" name="Porch5[]" value="Swing Set" />Swing Set[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Porch6[]" value="Chairs, Metal" />Chairs, Metal<input type="checkbox" name="Porch6[]" value="Lawn Statue" />Lawn Statue<input type="checkbox" name="Porch6[]" value="Trampoline" />Trampoline[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Porch7[]" value="Chairs, Wood" />Chairs, Wood<input type="checkbox" name="Porch7[]" value="Leaf Blower" />Leaf Blower<input type="checkbox" name="Porch7[]" value="Table, Large" />Table, Large[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Porch8[]" value="Garden Hose &amp; Tools" />Garden Hose &amp; Tools<input type="checkbox" name="Porch8[]" value="Outdoor Child Gym" />Outdoor Child Gym<input type="checkbox" name="Porch8[]" value="Table, Small" />Table, Small[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Porch9[]" value="Glider Or Settee" />Glider Or Settee<input type="checkbox" name="Porch9[]" value="Outdoor Child Slide" />Outdoor Child Slide<input type="checkbox" name="Porch9[]" value="Umbrella" />Umbrella[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Porch10[]" value="Ladder, 6&#039; Step" />Ladder, 6&#039; Step<input type="checkbox" name="Porch10[]" value="Outdoor Dry Racks" />Outdoor Dry Racks<input type="checkbox" name="Porch10[]" value="Wheelbarrow" />Wheelbarrow[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Porch11[]" value="Ladder, 8&#039; Metal" />Ladder, 8&#039; Metal<input type="checkbox" name="Porch11[]" value="Outdoor Swings" />Outdoor Swings[/one_third][one_half_last]  [/one_half_last]</p>
<p>[one_third]Rec. Room/ Garage/ Office[/one_third] [one_half_last]  [/one_half_last]</p>
<p>[one_third]<input type="checkbox" name="Rec1[]" value="Baby Carriage" />Baby Carriage<input type="checkbox" name="Rec1[]" value="Filing Cab. 3 Drawers" />Filing Cab. 3 Drawers<input type="checkbox" name="Rec1[]" value="Sewing Mach. W/Cabinet" />Sewing Mach. W/Cabinet[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Rec2[]" value="Barbells" />Barbells<input type="checkbox" name="Rec2[]" value="Filing Cab. 4 Drawers" />Filing Cab. 4 Drawers<input type="checkbox" name="Rec2[]" value="Sled" />Sled[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Rec3[]" value="Bicycle" />Bicycle<input type="checkbox" name="Rec3[]" value="Filing Cabinet Cardboard" />Filing Cabinet Cardboard<input type="checkbox" name="Rec3[]" value="Suitcase" />Suitcase[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Rec4[]" value="Bowling Ball/Bag" />Bowling Ball/Bag<input type="checkbox" name="Rec4[]" value="Folding Chairs" />Folding Chairs<input type="checkbox" name="Rec4[]" value="Table, Game" />Table, Game[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Rec5[]" value="Box, Book" />Box, Book<input type="checkbox" name="Rec5[]" value="Folding Cot" />Folding Cot<input type="checkbox" name="Rec5[]" value="Table, Ping Pong" />Table, Ping Pong[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Rec6[]" value="Box, Large" />Box, Large<input type="checkbox" name="Rec6[]" value="Footlockers" />Footlockers<input type="checkbox" name="Rec6[]" value="Tackle Box" />Tackle Box[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Rec7[]" value="Box, Medium" />Box, Medium<input type="checkbox" name="Rec7[]" value="Gas/Electric Heater" />Gas/Electric Heater<input type="checkbox" name="Rec7[]" value="Tire" />Tire[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Rec8[]" value="Grand Piano" />Grand Piano<input type="checkbox" name="Rec8[]" value="Baby Grand Piano" />Baby Grand Piano<input type="checkbox" name="Rec8[]" value="Upright Piano" />Upright Piano[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Rec9[]" value="Electric Piano" />Electric Piano<input type="checkbox" name="Rec9[]" value="Digital Piano" />Digital Piano<input type="checkbox" name="Rec9[]" value="Golf Kit" />Golf Kit[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Rec10[]" value="Box, Small" />Box, Small<input type="checkbox" name="Rec10[]" value="Golf Bag" />Golf Bag<input type="checkbox" name="Rec10[]" value="Tire With Rim" />Tire With Rim[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Rec11[]" value="Card Table" />Card Table<input type="checkbox" name="Rec11[]" value="Hot Tub" />Hot Tub<input type="checkbox" name="Rec11[]" value="Toolchest, Large" />Toolchest, Large[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Rec12[]" value="Child&#039;s Wagon" />Child&#039;s Wagon<input type="checkbox" name="Rec12[]" value="Metal Shelves" />Metal Shelves<input type="checkbox" name="Rec12[]" value="Toolchest, Medium" />Toolchest, Medium[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Rec13[]" value="Clothes Basket" />Clothes Basket<input type="checkbox" name="Rec13[]" value="Office Desk" />Office Desk<input type="checkbox" name="Rec13[]" value="Toolchest, Small" />Toolchest, Small[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Rec14[]" value="Clothes Hamper" />Clothes Hamper<input type="checkbox" name="Rec14[]" value="Pool Table Comp." />Pool Table Comp.<input type="checkbox" name="Rec14[]" value="Trampoline" />Trampoline[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Rec15[]" value="Cot, Folding" />Cot, Folding<input type="checkbox" name="Rec15[]" value="Pool Table Stand" />Pool Table Stand<input type="checkbox" name="Rec15[]" value="Trash Can" />Trash Can[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Rec16[]" value="Exercycle" />Exercycle<input type="checkbox" name="Rec16[]" value="Power Tool Hand" />Power Tool Hand<input type="checkbox" name="Rec16[]" value="Tricycle" />Tricycle[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Rec17[]" value="Exercise Machine" />Exercise Machine<input type="checkbox" name="Rec17[]" value="Power Tool Stand" />Power Tool Stand<input type="checkbox" name="Rec17[]" value="Utility Table" />Utility Table[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Rec18[]" value="Fan" />Fan<input type="checkbox" name="Rec18[]" value="Rug, Large" />Rug, Large<input type="checkbox" name="Rec18[]" value="Wastepaper Basket" />Wastepaper Basket<input type="checkbox" name="Rec18[]" value="Fern/Plants Stands" />Fern/Plants Stands[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Rec19[]" value="Sewing Machine Console" />Sewing Machine Console<input type="checkbox" name="Rec19[]" value="Work Bench" />Work Bench<input type="checkbox" name="Rec19[]" value="Filing Cab. 2 Drawers" />Filing Cab. 2 Drawers[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Rec20[]" value="Sewing Machine Portable" />Sewing Machine Portable<input type="checkbox" name="Rec20[]" value="Guitar" />Guitar<input type="checkbox" name="Rec20[]" value="Paintings" />Paintings[/one_third][one_half_last]  [/one_half_last]</p>
<p>[one_third]Electronics[/one_third] [one_half_last]  [/one_half_last]</p>
<p>[one_third]<input type="checkbox" name="Electronics1[]" value="Tv 80 Series" />Tv 80 Series<input type="checkbox" name="Electronics1[]" value="Computer Desk" />Computer Desk<input type="checkbox" name="Electronics1[]" value="Office Copier" />Office Copier[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Electronics2[]" value="Tv 70 Series" />Tv 70 Series<input type="checkbox" name="Electronics2[]" value="Computer Flat Screen" />Computer Flat Screen<input type="checkbox" name="Electronics2[]" value="Pc/Computer" />Pc/Computer[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Electronics3[]" value="Tv 60 Series" />Tv 60 Series<input type="checkbox" name="Electronics3[]" value="Computer Monitor/Screen" />Computer Monitor/Screen<input type="checkbox" name="Electronics3[]" value="Satellite, Lg" />Satellite, Lg[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Electronics4[]" value="Tv 50 Series" />Tv 50 Series<input type="checkbox" name="Electronics4[]" value="Computer Printer" />Computer Printer<input type="checkbox" name="Electronics4[]" value="Satellite, Sm" />Satellite, Sm[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Electronics5[]" value="Tv 40 Series" />Tv 40 Series<input type="checkbox" name="Electronics5[]" value="Tv Stand" />Tv Stand<input type="checkbox" name="Electronics5[]" value="Tower Speakers" />Tower Speakers[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Electronics6[]" value="Tv 30 Series" />Tv 30 Series<input type="checkbox" name="Electronics6[]" value="Blue Ray" />Blue Ray<input type="checkbox" name="Electronics6[]" value="Home Theatre" />Home Theatre[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Electronics7[]" value="Tv, Portable 13&quot;-15&quot;" />Tv, Portable 13&quot;-15&quot;<input type="checkbox" name="Electronics7[]" value="Dvd Player" />Dvd Player<input type="checkbox" name="Electronics7[]" value="Scanner" />Scanner[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Electronics8[]" value="Entertainment Center" />Entertainment Center<input type="checkbox" name="Electronics8[]" value="Shelf Speaker" />Shelf Speaker<input type="checkbox" name="Electronics8[]" value="Typewriter, Portable" />Typewriter, Portable[/one_third][one_half_last]  [/one_half_last]<br />
[one_third]<input type="checkbox" name="Electronics9[]" value="Fax Machine" />Fax Machine<input type="checkbox" name="Electronics9[]" value="Stereo Component" />Stereo Component<input type="checkbox" name="Electronics9[]" value="Vcrs" />Vcrs<input type="checkbox" name="Electronics9[]" value="Floor Speaker" />Floor Speaker[/one_third][one_half_last]  [/one_half_last]</p>
<p>[one_third]Totals[/one_third] [one_half_last]  [/one_half_last]</p>
<p>[one_half]<input type="text" name="t1" value="" size="40" aria-invalid="false" placeholder="Cubic Foot Volume" />[/one_half] [one_half_last]<input type="text" name="t2" value="" size="40" aria-invalid="false" placeholder="Estimated Weight" />[/one_half_last]</p>
<p>[one_half]<input type="text" name="textarea-6" value="" size="40" aria-invalid="false" placeholder="Additional Comments" />[/one_half] [one_half_last] [/one_half_last]</p>
<p><input type="submit" value="Submit" /></p>
</form> 			
<form action="/wp-admin/admin-ajax.php#wpcf7-f6220-o2" method="post" novalidate="novalidate">
<input type="hidden" name="_wpcf7" value="6220" />
<input type="hidden" name="_wpcf7_version" value="5.1.7" />
<input type="hidden" name="_wpcf7_locale" value="en_US" />
<input type="hidden" name="_wpcf7_unit_tag" value="wpcf7-f6220-o2" />
<input type="hidden" name="_wpcf7_container_post" value="0" />
<p><input type="text" name="nam" value="" size="40" aria-invalid="false" placeholder="Your Name" /></p>
<p>.<br />
.<br />
<input type="tel" name="tel" value="" size="40" aria-invalid="false" placeholder="Contact Number" /></p>
<p>.<br />
.<br />
<input type="text" name="date" value="" size="40" aria-invalid="false" placeholder="Enter Date" /></p>
<p>.<br />
.<br />
<input type="text" name="time" value="" size="40" aria-invalid="false" placeholder="Enter Time in AM / PM" /></p>
<p>[one_third]Moving Information[/one_third] [one_half_last]  [/one_half_last]</p>
<p><input type="date" name="mn" value="" aria-invalid="false" placeholder="City Moving From" /></p>
<p>.<br />
.<br />
<input type="text" name="mb" value="" size="40" aria-invalid="false" placeholder="City Moving To" /></p>
<p>[one_third]Boxes[/one_third] [one_half_last]  [/one_half_last]</p>
<p><input type="checkbox" name="Boxes[]" value="Book Box(Es)" />Book Box(Es)<input type="checkbox" name="Boxes[]" value="Large Box(Es)" />Large Box(Es)<input type="checkbox" name="Boxes[]" value="Picture(s)" />Picture(s)<input type="checkbox" name="Boxes[]" value="Dish Pack" />Dish Pack<input type="checkbox" name="Boxes[]" value="Medium Box(Es)" />Medium Box(Es)<input type="checkbox" name="Boxes[]" value="Mirror(s)" />Mirror(s)<input type="checkbox" name="Boxes[]" value="Extra Large Box(Es)" />Extra Large Box(Es)<input type="checkbox" name="Boxes[]" value="Small Box(Es)" />Small Box(Es)<input type="checkbox" name="Boxes[]" value="Wardrobe Box(Es)" />Wardrobe Box(Es)</p>
<p>[one_third]Bedroom[/one_third] [one_half_last]  [/one_half_last]</p>
<p><input type="checkbox" name="bedroomnn[]" value="Armoire, Lrg" />Armoire, Lrg<input type="checkbox" name="bedroomnn[]" value="Box, Wardrobe Lrg" />Box, Wardrobe Lrg<input type="checkbox" name="bedroomnn[]" value="Dresser, Triple" />Dresser, Triple<input type="checkbox" name="bedroomnn[]" value="Armoire, Sm" />Armoire, Sm<input type="checkbox" name="bedroomnn[]" value="Box, Wardrobe Sm" />Box, Wardrobe Sm<input type="checkbox" name="bedroomnn[]" value="Dresser, Vanity" />Dresser, Vanity<input type="checkbox" name="bedroomnn[]" value="Bed, Bunk (Set Of 2)" />Bed, Bunk (Set Of 2)<input type="checkbox" name="bedroomnn[]" value="Chair, Boudoir" />Chair, Boudoir<input type="checkbox" name="bedroomnn[]" value="Dresser/Vanity Bench" />Dresser/Vanity Bench<input type="checkbox" name="bedroomnn[]" value="Bed, King" />Bed, King<input type="checkbox" name="bedroomnn[]" value="Chair, Straight" />Chair, Straight<input type="checkbox" name="bedroomnn[]" value="Floor Lamp/Table Lamp" />Floor Lamp/Table Lamp<input type="checkbox" name="bedroomnn[]" value="Bed, Queen" />Bed, Queen<input type="checkbox" name="bedroomnn[]" value="Chaise Lounge" />Chaise Lounge<input type="checkbox" name="bedroomnn[]" value="Futon" />Futon<input type="checkbox" name="bedroomnn[]" value="Bed, Rollaway" />Bed, Rollaway<input type="checkbox" name="bedroomnn[]" value="Chest Of Drawers" />Chest Of Drawers<input type="checkbox" name="bedroomnn[]" value="Night Table" />Night Table<input type="checkbox" name="bedroomnn[]" value="Bed, Single/Hollywood" />Bed, Single/Hollywood<input type="checkbox" name="bedroomnn[]" value="Chest, Armoire" />Chest, Armoire<input type="checkbox" name="bedroomnn[]" value="Sm / Winthrop Desk" />Sm / Winthrop Desk<input type="checkbox" name="bedroomnn[]" value="Bed, Std/Double/Full" />Bed, Std/Double/Full<input type="checkbox" name="bedroomnn[]" value="Chest, Bachelor/Cedar" />Chest, Bachelor/Cedar<input type="checkbox" name="bedroomnn[]" value="Student Desk" />Student Desk<input type="checkbox" name="bedroomnn[]" value="Bed, Waterbed Base" />Bed, Waterbed Base<input type="checkbox" name="bedroomnn[]" value="Daybed/Captains Bed" />Daybed/Captains Bed<input type="checkbox" name="bedroomnn[]" value="Trunk" />Trunk<input type="checkbox" name="bedroomnn[]" value="Mattress King" />Mattress King<input type="checkbox" name="bedroomnn[]" value="Mattress Queen" />Mattress Queen<input type="checkbox" name="bedroomnn[]" value="Mattress Full" />Mattress Full<input type="checkbox" name="bedroomnn[]" value="Mattress Single" />Mattress Single<input type="checkbox" name="bedroomnn[]" value="Box Spring Single" />Box Spring Single<input type="checkbox" name="bedroomnn[]" value="Box Spring Queen" />Box Spring Queen<input type="checkbox" name="bedroomnn[]" value="Box Spring Full" />Box Spring Full<input type="checkbox" name="bedroomnn[]" value="Temper Pedic Mattress" />Temper Pedic Mattress<input type="checkbox" name="bedroomnn[]" value="Tv" />Tv<input type="checkbox" name="bedroomnn[]" value="Night Stand" />Night Stand<input type="checkbox" name="bedroomnn[]" value="Lamp Shade" />Lamp Shade<input type="checkbox" name="bedroomnn[]" value="Pillows" />Pillows<input type="checkbox" name="bedroomnn[]" value="Bookcase" />Bookcase<input type="checkbox" name="bedroomnn[]" value="Dresser, Double" />Dresser, Double<input type="checkbox" name="bedroomnn[]" value="Wardrobe, Large" />Wardrobe, Large<input type="checkbox" name="bedroomnn[]" value="Bookshelves Section" />Bookshelves Section<input type="checkbox" name="bedroomnn[]" value="Dresser, Single" />Dresser, Single<input type="checkbox" name="bedroomnn[]" value="Wardrobe, Small" />Wardrobe, Small</p>
<p>[one_third]Nursery[/one_third] [one_half_last]  [/one_half_last]</p>
<p><input type="checkbox" name="Nursery[]" value="Baby Carriage" />Baby Carriage<input type="checkbox" name="Nursery[]" value="Chair, Child. Reg &amp; Rock" />Chair, Child. Reg &amp; Rock<input type="checkbox" name="Nursery[]" value="Large, Rug" />Large, Rug<input type="checkbox" name="Nursery[]" value="Baby Crib" />Baby Crib<input type="checkbox" name="Nursery[]" value="Chair, High" />Chair, High<input type="checkbox" name="Nursery[]" value="Playpen" />Playpen<input type="checkbox" name="Nursery[]" value="Bassinet" />Bassinet<input type="checkbox" name="Nursery[]" value="Chest" />Chest<input type="checkbox" name="Nursery[]" value="Rocking Chair" />Rocking Chair<input type="checkbox" name="Nursery[]" value="Bed, Youth" />Bed, Youth<input type="checkbox" name="Nursery[]" value="Child Table" />Child Table<input type="checkbox" name="Nursery[]" value="Toy Chest" />Toy Chest</p>
<p>[one_third]Living Room[/one_third] [one_half_last]  [/one_half_last]</p>
<p><input type="checkbox" name="LivingRoom[]" value="Bar, Portable" />Bar, Portable<input type="checkbox" name="LivingRoom[]" value="Grandfather Clock" />Grandfather Clock<input type="checkbox" name="LivingRoom[]" value="Sectional Bookshelf" />Sectional Bookshelf<input type="checkbox" name="LivingRoom[]" value="Bench Fireside" />Bench Fireside<input type="checkbox" name="LivingRoom[]" value="Hall Tree, Large" />Hall Tree, Large<input type="checkbox" name="LivingRoom[]" value="Sofa, 3 Cushion" />Sofa, 3 Cushion<input type="checkbox" name="LivingRoom[]" value="Bookcase" />Bookcase<input type="checkbox" name="LivingRoom[]" value="Hall Tree, Rack" />Hall Tree, Rack<input type="checkbox" name="LivingRoom[]" value="Sofa, 4 Cush Hideabed" />Sofa, 4 Cush Hideabed<input type="checkbox" name="LivingRoom[]" value="Cedar Chest" />Cedar Chest<input type="checkbox" name="LivingRoom[]" value="Lamp, Floor Or Pole" />Lamp, Floor Or Pole<input type="checkbox" name="LivingRoom[]" value="Sofa, Loveseat" />Sofa, Loveseat<input type="checkbox" name="LivingRoom[]" value="Chair, Arm" />Chair, Arm<input type="checkbox" name="LivingRoom[]" value="Magazine Rack" />Magazine Rack<input type="checkbox" name="LivingRoom[]" value="Sofa, Per Section" />Sofa, Per Section<input type="checkbox" name="LivingRoom[]" value="Chair, Occasional" />Chair, Occasional<input type="checkbox" name="LivingRoom[]" value="Music Cabinet" />Music Cabinet<input type="checkbox" name="LivingRoom[]" value="Sofa, Rattan, Wicker" />Sofa, Rattan, Wicker<input type="checkbox" name="LivingRoom[]" value="Chair, Overstuffed" />Chair, Overstuffed<input type="checkbox" name="LivingRoom[]" value="Ottoman" />Ottoman<input type="checkbox" name="LivingRoom[]" value="Stereo Component" />Stereo Component<input type="checkbox" name="LivingRoom[]" value="Chair, Rocker" />Chair, Rocker<input type="checkbox" name="LivingRoom[]" value="Phone Stand" />Phone Stand<input type="checkbox" name="LivingRoom[]" value="Stereo, Console" />Stereo, Console<input type="checkbox" name="LivingRoom[]" value="Chair, Straight" />Chair, Straight<input type="checkbox" name="LivingRoom[]" value="Piano, Baby Grand" />Piano, Baby Grand<input type="checkbox" name="LivingRoom[]" value="Tables, Coffee" />Tables, Coffee<input type="checkbox" name="LivingRoom[]" value="Chair, Wicker" />Chair, Wicker<input type="checkbox" name="LivingRoom[]" value="Piano, Bench" />Piano, Bench<input type="checkbox" name="LivingRoom[]" value="Tables, Dropl/Occasional" />Tables, Dropl/Occasional<input type="checkbox" name="LivingRoom[]" value="Computer System" />Computer System<input type="checkbox" name="LivingRoom[]" value="Piano, Parlor Grand" />Piano, Parlor Grand<input type="checkbox" name="LivingRoom[]" value="Tables, End" />Tables, End<input type="checkbox" name="LivingRoom[]" value="Curio Cabinet" />Curio Cabinet<input type="checkbox" name="LivingRoom[]" value="Piano, Spinet/Console" />Piano, Spinet/Console<input type="checkbox" name="LivingRoom[]" value="Tv Stand" />Tv Stand<input type="checkbox" name="LivingRoom[]" value="Day Bed" />Day Bed<input type="checkbox" name="LivingRoom[]" value="Piano, Upright" />Piano, Upright<input type="checkbox" name="LivingRoom[]" value="Tv, Big Screen" />Tv, Big Screen<input type="checkbox" name="LivingRoom[]" value="Desk, Secy" />Desk, Secy<input type="checkbox" name="LivingRoom[]" value="Portable Record Player" />Portable Record Player<input type="checkbox" name="LivingRoom[]" value="Tv, Combination" />Tv, Combination<input type="checkbox" name="LivingRoom[]" value="Desk, Sm. Winthrop" />Desk, Sm. Winthrop<input type="checkbox" name="LivingRoom[]" value="Recliner" />Recliner<input type="checkbox" name="LivingRoom[]" value="Tv, Console" />Tv, Console<input type="checkbox" name="LivingRoom[]" value="Entertainment Center" />Entertainment Center<input type="checkbox" name="LivingRoom[]" value="Roll/Pad Rug, Large" />Roll/Pad Rug, Large<input type="checkbox" name="LivingRoom[]" value="Tv, Portable" />Tv, Portable<input type="checkbox" name="LivingRoom[]" value="Fireplace Equipment" />Fireplace Equipment<input type="checkbox" name="LivingRoom[]" value="Roll/Pad Rugs, Small" />Roll/Pad Rugs, Small<input type="checkbox" name="LivingRoom[]" value="Unit, Wall Lrg" />Unit, Wall Lrg<input type="checkbox" name="LivingRoom[]" value="Footstool" />Footstool<input type="checkbox" name="LivingRoom[]" value="Secretary Desk" />Secretary Desk<input type="checkbox" name="LivingRoom[]" value="Unit, Wall Sm" />Unit, Wall Sm</p>
<p>[one_third]Dining Room[/one_third] [one_half_last]  [/one_half_last]</p>
<p><input type="checkbox" name="DiningRoom[]" value="Bakers Rack" />Bakers Rack<input type="checkbox" name="DiningRoom[]" value="Dining Chair" />Dining Chair<input type="checkbox" name="DiningRoom[]" value="Rugs, Lg. Roll/Pad" />Rugs, Lg. Roll/Pad<input type="checkbox" name="DiningRoom[]" value="Base Buffet" />Base Buffet<input type="checkbox" name="DiningRoom[]" value="Dining Table" />Dining Table<input type="checkbox" name="DiningRoom[]" value="Rugs, Sm. Roll/Pad" />Rugs, Sm. Roll/Pad<input type="checkbox" name="DiningRoom[]" value="Box, Dish Pack" />Box, Dish Pack<input type="checkbox" name="DiningRoom[]" value="Harvest Bench" />Harvest Bench<input type="checkbox" name="DiningRoom[]" value="Server" />Server<input type="checkbox" name="DiningRoom[]" value="China Cabinet" />China Cabinet<input type="checkbox" name="DiningRoom[]" value="Hutch" />Hutch<input type="checkbox" name="DiningRoom[]" value="Tea Cart" />Tea Cart<input type="checkbox" name="DiningRoom[]" value="Corner Cabinet" />Corner Cabinet<input type="checkbox" name="DiningRoom[]" value="Lamp" />Lamp</p>
<p>[one_third]Kitchen[/one_third] [one_half_last]  [/one_half_last]</p>
<p><input type="checkbox" name="Kitchen[]" value="Baker&#039;s Rack" />Baker&#039;s Rack<input type="checkbox" name="Kitchen[]" value="Harvest Bench" />Harvest Bench<input type="checkbox" name="Kitchen[]" value="Stool" />Stool<input type="checkbox" name="Kitchen[]" value="Box, Dish-Pack" />Box, Dish-Pack<input type="checkbox" name="Kitchen[]" value="Kitchen Cabinet" />Kitchen Cabinet<input type="checkbox" name="Kitchen[]" value="Table" />Table<input type="checkbox" name="Kitchen[]" value="Breadmaker" />Breadmaker<input type="checkbox" name="Kitchen[]" value="Lamp" />Lamp<input type="checkbox" name="Kitchen[]" value="Tea Cart" />Tea Cart<input type="checkbox" name="Kitchen[]" value="Breakfast Suite, Chairs" />Breakfast Suite, Chairs<input type="checkbox" name="Kitchen[]" value="Microwave Oven" />Microwave Oven<input type="checkbox" name="Kitchen[]" value="Toaster Oven" />Toaster Oven<input type="checkbox" name="Kitchen[]" value="Breakfast Table" />Breakfast Table<input type="checkbox" name="Kitchen[]" value="Microwave Stand" />Microwave Stand<input type="checkbox" name="Kitchen[]" value="Utility Cabinet" />Utility Cabinet<input type="checkbox" name="Kitchen[]" value="China Cabinet" />China Cabinet<input type="checkbox" name="Kitchen[]" value="Serving Cart" />Serving Cart</p>
<p>[one_third]Appliances[/one_third] [one_half_last]  [/one_half_last]</p>
<p><input type="checkbox" name="Appliances[]" value="Air Cond.-Window, Lrg" />Air Cond.-Window, Lrg<input type="checkbox" name="Appliances[]" value="Freezer 16 Or Over" />Freezer 16 Or Over<input type="checkbox" name="Appliances[]" value="Refrig. 11 Cu. Ft. Or More" />Refrig. 11 Cu. Ft. Or More<input type="checkbox" name="Appliances[]" value="Air Cond.-Window, Sm" />Air Cond.-Window, Sm<input type="checkbox" name="Appliances[]" value="Range, 20&#039;&#039; Wide" />Range, 20&#039;&#039; Wide<input type="checkbox" name="Appliances[]" value="Shopvac" />Shopvac<input type="checkbox" name="Appliances[]" value="Dehumidifier" />Dehumidifier<input type="checkbox" name="Appliances[]" value="Range, 30&#039;&#039; Wide" />Range, 30&#039;&#039; Wide<input type="checkbox" name="Appliances[]" value="Stackable Washer/Dryer" />Stackable Washer/Dryer<input type="checkbox" name="Appliances[]" value="Dishwasher" />Dishwasher<input type="checkbox" name="Appliances[]" value="Range, 36&#039;&#039; Wide" />Range, 36&#039;&#039; Wide<input type="checkbox" name="Appliances[]" value="Trash Compactor" />Trash Compactor<input type="checkbox" name="Appliances[]" value="Dryer" />Dryer<input type="checkbox" name="Appliances[]" value="Refrig. 6 Cu. Ft. Or Less" />Refrig. 6 Cu. Ft. Or Less<input type="checkbox" name="Appliances[]" value="Vacuum Cleaner" />Vacuum Cleaner<input type="checkbox" name="Appliances[]" value="Freezer 10 Or Less" />Freezer 10 Or Less<input type="checkbox" name="Appliances[]" value="Refrig. 7 To 10 Cu.Ft." />Refrig. 7 To 10 Cu.Ft.<input type="checkbox" name="Appliances[]" value="Washing Machine" />Washing Machine<input type="checkbox" name="Appliances[]" value="Freezer 11 Or 15" />Freezer 11 Or 15</p>
<p>[one_third]Porch/ Outdoor/ Patio[/one_third] [one_half_last]  [/one_half_last]</p>
<p><input type="checkbox" name="PorchOutdoorPatio[]" value="Bbq Grill Large" />Bbq Grill Large<input type="checkbox" name="PorchOutdoorPatio[]" value="Ladder, Extension" />Ladder, Extension<input type="checkbox" name="PorchOutdoorPatio[]" value="Picnic Bench" />Picnic Bench<input type="checkbox" name="PorchOutdoorPatio[]" value="Bbq Grill Medium" />Bbq Grill Medium<input type="checkbox" name="PorchOutdoorPatio[]" value="Lawn Mower, Hand" />Lawn Mower, Hand<input type="checkbox" name="PorchOutdoorPatio[]" value="Picnic Table" />Picnic Table<input type="checkbox" name="PorchOutdoorPatio[]" value="Bbq Grill Small" />Bbq Grill Small<input type="checkbox" name="PorchOutdoorPatio[]" value="Lawn Mower, Power" />Lawn Mower, Power<input type="checkbox" name="PorchOutdoorPatio[]" value="Sand Box" />Sand Box<input type="checkbox" name="PorchOutdoorPatio[]" value="Birdbath" />Birdbath<input type="checkbox" name="PorchOutdoorPatio[]" value="Lawn Mower, Riding (Hp)" />Lawn Mower, Riding (Hp)<input type="checkbox" name="PorchOutdoorPatio[]" value="Spreader" />Spreader<input type="checkbox" name="PorchOutdoorPatio[]" value="Chairs, Aluminum" />Chairs, Aluminum<input type="checkbox" name="PorchOutdoorPatio[]" value="Lawn Roller" />Lawn Roller<input type="checkbox" name="PorchOutdoorPatio[]" value="Swing Set" />Swing Set<input type="checkbox" name="PorchOutdoorPatio[]" value="Chairs, Metal" />Chairs, Metal<input type="checkbox" name="PorchOutdoorPatio[]" value="Lawn Statue" />Lawn Statue<input type="checkbox" name="PorchOutdoorPatio[]" value="Trampoline" />Trampoline<input type="checkbox" name="PorchOutdoorPatio[]" value="Chairs, Wood" />Chairs, Wood<input type="checkbox" name="PorchOutdoorPatio[]" value="Leaf Blower" />Leaf Blower<input type="checkbox" name="PorchOutdoorPatio[]" value="Table, Large" />Table, Large<input type="checkbox" name="PorchOutdoorPatio[]" value="Garden Hose &amp; Tools" />Garden Hose &amp; Tools<input type="checkbox" name="PorchOutdoorPatio[]" value="Outdoor Child Gym" />Outdoor Child Gym<input type="checkbox" name="PorchOutdoorPatio[]" value="Table, Small" />Table, Small<input type="checkbox" name="PorchOutdoorPatio[]" value="Glider Or Settee" />Glider Or Settee<input type="checkbox" name="PorchOutdoorPatio[]" value="Outdoor Child Slide" />Outdoor Child Slide<input type="checkbox" name="PorchOutdoorPatio[]" value="Umbrella" />Umbrella<input type="checkbox" name="PorchOutdoorPatio[]" value="Ladder, 6&#039; Step" />Ladder, 6&#039; Step<input type="checkbox" name="PorchOutdoorPatio[]" value="Outdoor Dry Racks" />Outdoor Dry Racks<input type="checkbox" name="PorchOutdoorPatio[]" value="Wheelbarrow" />Wheelbarrow<input type="checkbox" name="PorchOutdoorPatio[]" value="Ladder, 8&#039; Metal" />Ladder, 8&#039; Metal<input type="checkbox" name="PorchOutdoorPatio[]" value="Outdoor Swings" />Outdoor Swings</p>
<p>[one_third]Rec. Room/ Garage/ Office[/one_third] [one_half_last]  [/one_half_last]</p>
<p><input type="checkbox" name="Rec.RoomGarageOffice[]" value="Baby Carriage" />Baby Carriage<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Filing Cab. 3 Drawers" />Filing Cab. 3 Drawers<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Sewing Mach. W/Cabinet" />Sewing Mach. W/Cabinet<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Barbells" />Barbells<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Filing Cab. 4 Drawers" />Filing Cab. 4 Drawers<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Sled" />Sled<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Bicycle" />Bicycle<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Filing Cabinet Cardboard" />Filing Cabinet Cardboard<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Suitcase" />Suitcase<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Bowling Ball/Bag" />Bowling Ball/Bag<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Folding Chairs" />Folding Chairs<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Table, Game" />Table, Game<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Box, Book" />Box, Book<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Folding Cot" />Folding Cot<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Table, Ping Pong" />Table, Ping Pong<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Box, Large" />Box, Large<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Footlockers" />Footlockers<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Tackle Box" />Tackle Box<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Box, Medium" />Box, Medium<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Gas/Electric Heater" />Gas/Electric Heater<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Tire" />Tire<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Grand Piano" />Grand Piano<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Baby Grand Piano" />Baby Grand Piano<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Upright Piano" />Upright Piano<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Electric Piano" />Electric Piano<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Digital Piano" />Digital Piano<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Golf Kit" />Golf Kit<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Box, Small" />Box, Small<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Golf Bag" />Golf Bag<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Tire With Rim" />Tire With Rim<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Card Table" />Card Table<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Hot Tub" />Hot Tub<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Toolchest, Large" />Toolchest, Large<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Child&#039;s Wagon" />Child&#039;s Wagon<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Metal Shelves" />Metal Shelves<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Toolchest, Medium" />Toolchest, Medium<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Clothes Basket" />Clothes Basket<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Office Desk" />Office Desk<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Toolchest, Small" />Toolchest, Small<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Clothes Hamper" />Clothes Hamper<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Pool Table Comp." />Pool Table Comp.<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Trampoline" />Trampoline<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Cot, Folding" />Cot, Folding<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Pool Table Stand" />Pool Table Stand<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Trash Can" />Trash Can<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Exercycle" />Exercycle<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Power Tool Hand" />Power Tool Hand<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Tricycle" />Tricycle<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Exercise Machine" />Exercise Machine<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Power Tool Stand" />Power Tool Stand<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Utility Table" />Utility Table<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Fan" />Fan<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Rug, Large" />Rug, Large<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Wastepaper Basket" />Wastepaper Basket<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Fern/Plants Stands" />Fern/Plants Stands<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Sewing Machine Console" />Sewing Machine Console<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Work Bench" />Work Bench<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Filing Cab. 2 Drawers" />Filing Cab. 2 Drawers<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Sewing Machine Portable" />Sewing Machine Portable<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Guitar" />Guitar<input type="checkbox" name="Rec.RoomGarageOffice[]" value="Paintings" />Paintings</p>
<p>[one_third]Electronics[/one_third] [one_half_last]  [/one_half_last]</p>
<p><input type="checkbox" name="Electronics[]" value="Tv 80 Series" />Tv 80 Series<input type="checkbox" name="Electronics[]" value="Computer Desk" />Computer Desk<input type="checkbox" name="Electronics[]" value="Office Copier" />Office Copier<input type="checkbox" name="Electronics[]" value="Tv 70 Series" />Tv 70 Series<input type="checkbox" name="Electronics[]" value="Computer Flat Screen" />Computer Flat Screen<input type="checkbox" name="Electronics[]" value="Pc/Computer" />Pc/Computer<input type="checkbox" name="Electronics[]" value="Tv 60 Series" />Tv 60 Series<input type="checkbox" name="Electronics[]" value="Computer Monitor/Screen" />Computer Monitor/Screen<input type="checkbox" name="Electronics[]" value="Satellite, Lg" />Satellite, Lg<input type="checkbox" name="Electronics[]" value="Tv 50 Series" />Tv 50 Series<input type="checkbox" name="Electronics[]" value="Computer Printer" />Computer Printer<input type="checkbox" name="Electronics[]" value="Satellite, Sm" />Satellite, Sm<input type="checkbox" name="Electronics[]" value="Tv 40 Series" />Tv 40 Series<input type="checkbox" name="Electronics[]" value="Tv Stand" />Tv Stand<input type="checkbox" name="Electronics[]" value="Tower Speakers" />Tower Speakers<input type="checkbox" name="Electronics[]" value="Tv 30 Series" />Tv 30 Series<input type="checkbox" name="Electronics[]" value="Blue Ray" />Blue Ray<input type="checkbox" name="Electronics[]" value="Home Theatre" />Home Theatre<input type="checkbox" name="Electronics[]" value="Tv, Portable 13&quot;-15&quot;" />Tv, Portable 13&quot;-15&quot;<input type="checkbox" name="Electronics[]" value="Dvd Player" />Dvd Player<input type="checkbox" name="Electronics[]" value="Scanner" />Scanner<input type="checkbox" name="Electronics[]" value="Entertainment Center" />Entertainment Center<input type="checkbox" name="Electronics[]" value="Shelf Speaker" />Shelf Speaker<input type="checkbox" name="Electronics[]" value="Typewriter, Portable" />Typewriter, Portable<input type="checkbox" name="Electronics[]" value="Fax Machine" />Fax Machine<input type="checkbox" name="Electronics[]" value="Stereo Component" />Stereo Component<input type="checkbox" name="Electronics[]" value="Vcrs" />Vcrs<input type="checkbox" name="Electronics[]" value="Floor Speaker" />Floor Speaker</p>
<p>[one_third]Totals[/one_third] [one_half_last]  [/one_half_last]</p>
<p><input type="text" name="t1" value="" size="40" aria-invalid="false" placeholder="Cubic Foot Volume" /></p>
<p>.<br />
.<br />
<input type="text" name="t2" value="" size="40" aria-invalid="false" placeholder="Estimated Weight" /></p>
<p>.<br />
.<br />
<input type="text" name="textarea-6" value="" size="40" aria-invalid="false" placeholder="Additional Comments" /></p>
<p><input type="submit" value="Submit" /></p>
</form>