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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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