Confirmation Number:
Reg Numb or PO Numb:
Est Weight:
Method of Payment:
Pack Date:
Load Date:
Delivery Date:
Request Service Date:
Bill Van Line
COD to Customer
Origin:
Destination:
Origin and Destination:
Origin
*Name:
*Address Line 1:
Address Line 2:
*City:
*State:
*Home Phone:
*Work Phone:
Destination
Name:
Address Line 1:
Address Line 2:
City:
State:
Home Phone:
Work Phone:
Authorized Services:
Additional Items
or Comments:
Crates:
*Crate Information:
*LxWxH:
Actual
Est. Item
Special Remarks:
Requester of Service
*Name:
*Street Address:
*Company Name:
*Local Phone Number:
*City:
*State:
*Zip Code:
*Toll Free Phone Number:
*Fax:
If you have questions regarding your submission please call 614.367.9970
To dowload a work form click
here
To download a crate form click
here
Email completed forms by clicking
here
Washer
Dryer
Range
Ice Maker
Waterbed
G/F Clock
Pool Table
Light Fixt.
Ceiling Fan
Swing Set
Hanging Pictures
TV's
Mirrors
Shipping Items
Office Furniture
Front Load Washers
Exercise Equipment