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Large Item Pickup Request

2. Today's Date*
   Today's Date

3. Requested Pickup Date (Thursdays Only)*
   Requested Pickup Date (Thursdays Only)

5. First Name*

6. Last Name*

8. Pickup Address*

10. Phone Number (if you would like confirmation by phone)

12. Items to Be Picked Up (Limit 5 Items)

    1. Mattress or Box Spring - $25.88 each
    2. Couch or Sofa - $35.68 each
    3. Recliner or Small Loveseat - $25.88 each
    4. Bag/Box of Trash (under 25 lbs) - $18.89 each
    5. Large Appliance (Not Refrigerator or Freezer) - $35.68 each
    6. Refrigerator or Freezer - $41.97 each
    7. Bed Frame or Headboard - $18.89 each
    8. Night Stand, Coffee Table - $18.89 each
    9. Dresser, Bookcase - $25.88 each
    10. Kitchen Table & Chairs - $25.88 each
    11. Rolled Carpet - $18.89 each
    12. Item Not On List (Under 25 lbs) - $18.89 each
    13. Item Not On List (25-40 lbs) - $25.88 each
    14. Item Not On List (41-75 lbs) - $35.68 each

14. Item(s) Not On List (Please Describe and Indicate Quantity)

16. Mattress Quantity
    -- Select One --12345

17. Couch/Sofa Quantity
    -- Select One --12345

18. Recliner/Loveseat Quantity
    -- Select One --12345

19. Bag/Box of Trash Quantity
    -- Select One --12345

21. Large Appliance Quantity
    -- Select One --12345

22. Refrigerator/Freezer Quan.
    -- Select One --12345

23. Bed Frame/Headbd Quan.
    -- Select One --12345

24. Nightstand/Coffee Tbl. Quan.
    -- Select One --12345

26. Dresser/Bookcase Quan.
    -- Select One --12345

27. Kitchen Table/Chairs Quan.
    -- Select One --12345

28. Rolled Carpet Quantity
    -- Select One --12345

29. Other Item Quantity
    -- Select One --12345

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31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

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