Their data and further information (Data with * must be indicated)
Company / Private	Private Company
Address*	Madam Sir
Name*		Telephone - business
First Name*		Telephone private*
Address*		Telephone mobile
Postal code*		E-Mail Adress
Place*
Old and new address
Removal of		Removal after
Address		Address
Postal code		Postal code
Place		Place
Floor		Floor
Elevator available	---- YesNo	Elevator available	---- YesNo
Do you pack yourself?	---- YesNo	Do you pack yourself?	---- YesNo
Number of rooms		Number of rooms
Removal date	Day 12345678910111213141516171819202122232425262728293031 Month JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Year 2011201220132014201520162017201820192020
Storage into furniture warehouse?	---- YesNo
Dis-/ re-assembly
Cabinet	-- select please -- only disassemblyonly re-assemblyDis- + re-assembly	Bed	-- select please -- only disassemblyonly re-assemblyDis- + re-assembly
Shelves	-- select please -- only disassemblyonly re-assemblyDis- + re-assembly	Double bed	-- select please -- only disassemblyonly re-assemblyDis- + re-assembly
Sliding door cabinet	-- select please -- only disassemblyonly re-assemblyDis- + re-assembly	Child / floor bed	-- select please -- only disassemblyonly re-assemblyDis- + re-assembly
Sideboard	-- select please -- only disassemblyonly re-assemblyDis- + re-assembly	Desk / Office	-- select please -- only disassemblyonly re-assemblyDis- + re-assembly
Chest of drawers	-- select please -- only disassemblyonly re-assemblyDis- + re-assembly	Machines	-- select please -- only disassemblyonly re-assemblyDis- + re-assembly
Safe	-- select please -- YesNo	Upright Piano / Grand Piano	-- select please -- YesNo
Remarks