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Value Card Alliance Customer Page
CUSTOMER INFORMATION
Are You Needing Emergency Services?
Are you a Returning customer?
YES (Welcome Back)
NO - I'm a New Customer
What Service(s) Do You Need (Check ALL that Apply):
Labor Service Only (No Moving Truck Needed)
Moving Service (Includes Truck)
Delivery Service (1-6 Large Items)
Safe Relocation Service
Piano Relocation Service
Pool Table Relocation Service
Jacuzzi / Hot-Tub Relocation Service
Junk Removal / Location Clean Up Service
Office / House Cleaning Service
Carpet / Tile Cleaning Service
Water Clean-Up Restoration Service
Date of Requested Service:
What Time of Day Would You Like Service(s) On:
V.C.A. Customer Business Name:
Customers Name:
Customers Phone Number:
Customers Email:
Customer Address of Service ORIGINATION:
Customer Address of Service DESTINATION:
Address of ANY ADDITIONAL STOPS (If Applicable):
Estimated Miles Distance Between Destinations:
Number of Men Requested:
STRUCTURE INFORMATION
TYPE OF STRUCTURE Service(s) at ORIGINATION:
House
Apartment
Condo / Townhome
Office Complex
Storage Unit
Mobile Storage Unit
High Rise Building Complex
Commercial Building
Mobile Home
Log Cabin
Other
Overall Square Feet of Structure at ORIGINATION:
Number of ALL ROOMS at ORIGINATION:
Features of Structure at ORIGINATION:
1 Story
2 Story
3 Story
4+ Stories
Stairs
Elevator
Short Approach
Long Approach
Please Describe Specifics of Stairs, Approaches, Landing and Space at *COMING OUT OF* LOCATION (Distance, Access etc):
TYPE OF STRUCTURE at DESTINATION:
House
Apartment
Condo / Townhome
Office Complex
Storage Unit
Mobile Storage Unit
High Rise Building Complex
Commercial Building
Mobile Home
Log Cabin
Other
Overall Square Feet of Structure at DESTINATION:
Number of ALL ROOMS at DESTINATION:
Features of Structure at DESTINATION:
1 Story
2 Story
3 Story
4+ Stories
Stairs
Elevator
Short Approach
Long Approach
Please Describe Specifics of Stairs, Approaches, Landing and Space at *GOING INTO* LOCATION (Distance, Access etc):
Does Either Structure Has a SECURITY GATE? If So, What Is the Security Code(s)?:
SERVICE(S) INFORMATION
ESTIMATED Number of BOXES:
Estimated # of Bags:
Estimated # of Containers:
Level of Packing / Unpacking Needed:
ESTIMATED Number of LARGE ITEMS to Be Moved (Anything Larger Than a Night Stand):
Estimated # of Large Items that are "Over 75lbs":
Special Items Included in Service(Check ALL that Apply):
Large Hutch / Cabinet
Large Glass Pieces
Large Safe
Large Pottery / Planters
Large Paintings / Hanging Pieces
Organ / Piano
Pool Table
Fish Tank / Aquarium
Gas Powered Engines
Refrigerator / Freezer
Washer / Dryer
BBQ Grill
Lawn Furniture
Antiques
Please Describe any Special Features or Notes of the Move(Safe, Piano, Appliance, ETC Specifics):
Misc. Items (List Anything That You Haven't Listed Already):
Any Items that you are or might be DONATING:
Level Assembly / Disassembly Needed:
What will be your PREFERED METHOD OF PAYMENT(Check ALL that Apply):
Cash
Value Card Alliance Barter Points
Credit/Debit
Check
Money Order
Other

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