Name*
Email*
Phone*
Address*
Apt, Ste, Bldg
City*
State*
Zip Code*
Name Purchased Under or Customer ID (if different from your own)
Were the items originally Delivered or Picked-Up? Delivered
Picked Up
Has the furniture been moved from its original location? Yes
No
If so, where was the furniture originally delivered?
Delivery Date or Date Picked-Up (if you have it)
Item(s) that require service
Comments*
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