First Name:    Last Name: 

E-Mail Address: 

Residence Phone:    Best time to contact:   

Business/Alternate Phone:  Best time to contact: 

 (Please Remember to list Area/Country Codes!)

Moving From:  USA    Other:  

Address: 

City:    State:  Select AL AK AZ AR CA CO CT DE DC GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VI VA WA VW WI WY    Zip Code:

Country/Province:     Postal Code:  

Moving To:  USA    Other: 

Address: 

City:    State:  Select AL AK AZ AR CA CO CT DE DC GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VI VA WA VW WI WY     Zip Code:

Country/Province:     Postal Code:  

Approximate Move Date:    Select January February March April May June July August September October November December   00 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   Year 2005 2006 2007 2008

Type of Relocation: Select One Local Intrastate State-To-State International

      - If this is an INTERNATIONAL Move - Type of Service Requested:  Select Door to Door Door to Port Port to Port Port to Door

Total Number of Rooms Select 1-2 3-4 5-6 7-8 9-10 11+ Auto Only    Garage?  Select Yes No    Attic?  Select Yes No

Specialty Items:  Piano  Pool Table  Appliances  Freezer  Auto  Boat  Camper

Other Specialty Items: 

Special Concerns: 

How did you hear of Smart Moves? Select One JCI Agent Referral Internet Search Referral Received Mailer Magazine Advertisement TV Ad Radio Ad

     - If other, please specify: 

Type of move:  Self paid    Employer paid

If employer paid, who is employer?