Personal Information
Customer name*:
Customer email*:    
Phone*:    
Uplift address: Date:
Street:
City/Suburb*: 
State*:
Postcode:
Delivery address:   Date:
Street:
City/Suburb*: 
State*:
Postcode:

Select which is applicable for your needs
Cartons required: Yes No   Carton packing required: Yes No
Carton unpack required: Yes No   Storage required: Yes No
 

Job details
Access Point of pick up Point of delivery
House, flat, unit, townhouse or store
Ground floor, any stairs, if so how many
Multi storey, No of floors
Lift
Does the dwelling slope up or down from road level?
How steep is this above slope?
Can truck be backed down the driveway? Yes No Yes No
How close can truck get to the dwelling
Other
""

Any heavy, large or unusual items. Are we required to disassemble or reassemble, dismount or remount any items.
Insurance Information
Insurance - Would you like the details to be explained? - Yes No
Transit cover required - Cover A or B
Goods value $ Premium cost $ Excess $150.00
Additional comments:

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