Please fill out this form then print and fax or 'click' the submit button on the bottom to send by email

* = Required Fields

Personal Details
First Name	*
Last Name	*
Email	*
Work Phone
Home Phone
Fax
Mobile

Contact Type
How would you like to be contacted? : *		Phone
		Fax
		Email

Pickup Address
Unit No.
Floor No.		Select any that apply:
Street No.	*	Steep Driveway
Address	*	We are in a unit or flat
Suburb/Town	*	The units/flats have a lift
State	Select state ACT NSW NT QLD SA TAS VIC WA *	Narrow Driveway
Postcode		Narrow Street

Delivery Address
Delivery: *		I require Caloundra Removals & Storage to store my furniture and effects for weeks
		Deliver to (full address to be advised)
		Deliver to the following address

Unit No.
Floor No.		Select any that apply:
Street No.		Steep Driveway
Address		We are in a unit or flat
Suburb/Town	*	The units/flats have a lift
State	Select state ACT NSW NT QLD SA TAS VIC WA *	Narrow Driveway
Postcode		Narrow Street

Relocation Details
Pickup Date	* (dd/mm/yyyy)
Delivery Date	(dd/mm/yyyy)
Storage Required for weeks

Bedroom 1 Items
Item	Qty	Item	Qty

Bedroom 2 Items
Item	Qty	Item	Qty

Bedroom 3 Items
Item	Qty	Item	Qty

Bedroom 4 Items
Item	Qty	Item	Qty

Dining Room Items
Item	Qty	Item	Qty

Lounge Room Items
Item	Qty	Item	Qty

Kitchen Items
Item	Qty	Item	Qty

Laundry Items
Item	Qty	Item	Qty

Study Items
Item	Qty	Item	Qty

Outside Items
Item	Qty	Item	Qty

Sundry Items
Item	Qty	Item	Qty

Hall Items
Item	Qty	Item	Qty

Family Room Items
Item	Qty	Item	Qty

Relocation of other items or Other relocation services.

This may include Pets, Motor Vehicles, Boat Transport or any service requirement

Special Instruction or Comments

If you have any concerns please list them here so we can ensure your instructions are carried out during your relocation

Professional Packing Services

Do you require Caloundra Removals to carry out professional packing services on your behalf? Full pack | Fragile pack only | No Packing

Should you select professional packing services we will provide a per carton price to supply and professionally pack including all materials.

Insurance Confirmation
My calculated household insurance value:	$
I require full cover insurance	Yes | No
I require restricted cover insurance	Yes | No
I require in store insurance	Yes | No
I have read and understand the Product Disclosure Statement	Yes | No
I have read and understand the Financial Services Guide	Yes | No
I have read and understand the Policy Wording	Yes | No

Where did you find us?
Recommendation
Used Caloundra Removals before
Yellow Pages Book
Which Book?
Yellow Pages Online
Search Engine (ie Google)
Saw Vehicle
Other
If other, describe