Title

Name

Appointment Date/Time

Removal Date

Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month: 01 02 03 04 05 06 07 08 09 10 11 12 Year: 2007 2008 2009

Collection Address

Delivery Address

Home Number

Work Number

Mobile Number

Fax Number

Email

Building Type :

Floor(G)(1)(2) etc:

Stairs :

No.Flight None 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 No.Corners: None 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
Wide: Narrow: Steep:

Lifts :

Parking at Building :

Distance to Door :

Access to Building :

Building Type :

Floor(G)(1)(2) etc:

Stairs :

No.Flights: None 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 No.Corners: None 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
Wide: Narrow: Steep:

Lifts :

Parking at Building :

Distance to Door :

Access to Building :

Do you require our packing service ?

Which type of service ?

Number of boxes required (Approx) ?

Do you require us to dismantle any furniture ?

Yes No
If Yes please state what:

Are there any unusual items to be moved ?
(Shed, Slabs, Piano, etc)

Yes No
If Yes please state what:

Are there any carpets to be lifted or moved ?

None Yes No

If Yes please state how many:

None 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Do you require us to empty your loft ?

If you think there is something important about your removal that we have not asked, please state below.

Please note: that the number of removal days is determined by the type of move.