Date *

MM

DD

YYYY

Time *

Hour

Minute

Second

AM PM

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

BAGS OF JUNK *

2 bAGS

3 BAGS

FURNITURE REMOVAL *

DRESSER

NIGHTSTAND

OTHER

SLEEP EQIUPMENT *

MATTRESS

BOX SPRING

OTHER

ADDITIONAL MORE ITEMS *

A couple of dining chairs

1 rolled-up carpet

A few moving boxes or totes

A small appliance (like a microwave, fan, or mini fridge)