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2. Today's Date*
   Today's Date
3. Requested Pickup Date (Wed. or Thurs. Only)*
   Requested Pickup Date (Wed. or Thurs. 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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32. Email address

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