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Large Item Pickup Request
This form has been modified since it was saved. Please review all fields before submitting.
Today's Date
*
Today's Date
Requested Pickup Date (Thursdays Only)
*
Requested Pickup Date (Thursdays Only)
First Name
*
Last Name
*
Pickup Address
*
Phone Number (if you would like confirmation by phone)
Items to Be Picked Up (Limit 5 Items)
Mattress or Box Spring - $25.88 each
Couch or Sofa - $35.68 each
Recliner or Small Loveseat - $25.88 each
Bag/Box of Trash (under 25 lbs) - $18.89 each
Large Appliance (Not Refrigerator or Freezer) - $35.68 each
Refrigerator or Freezer - $41.97 each
Bed Frame or Headboard - $18.89 each
Night Stand, Coffee Table - $18.89 each
Dresser, Bookcase - $25.88 each
Kitchen Table & Chairs - $25.88 each
Rolled Carpet - $18.89 each
Item Not On List (Under 25 lbs) - $18.89 each
Item Not On List (25-40 lbs) - $25.88 each
Item Not On List (41-75 lbs) - $35.68 each
Item(s) Not On List (Please Describe and Indicate Quantity)
Mattress Quantity
-- Select One --
1
2
3
4
5
Couch/Sofa Quantity
-- Select One --
1
2
3
4
5
Recliner/Loveseat Quantity
-- Select One --
1
2
3
4
5
Bag/Box of Trash Quantity
-- Select One --
1
2
3
4
5
Large Appliance Quantity
-- Select One --
1
2
3
4
5
Refrigerator/Freezer Quan.
-- Select One --
1
2
3
4
5
Bed Frame/Headbd Quan.
-- Select One --
1
2
3
4
5
Nightstand/Coffee Tbl. Quan.
-- Select One --
1
2
3
4
5
Dresser/Bookcase Quan.
-- Select One --
1
2
3
4
5
Kitchen Table/Chairs Quan.
-- Select One --
1
2
3
4
5
Rolled Carpet Quantity
-- Select One --
1
2
3
4
5
Other Item Quantity
-- Select One --
1
2
3
4
5
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