Move Request Form Contact Information Your Name* Email Address* Email is my preferred contact method Phone Number Phone is my preferred contact method Type of Move I will pay United directly My employer will pay United directly My employer has given me a lump-sum amount Employer (if applicable) Move Date* Format: MM-DD-YYYY Starting Address* Starting City* State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP Destination Address* Destination City* State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP About Your Household Number of Bedrooms* Other Rooms Kitchen Living Room Dining Room Den Play Room Basement Office Patio Shed Attic Garage Other Will your cars need to be transported? Yes No If yes, number of cars Additional Information When are you available to meet for a formal estimate? (Monday-Friday, 8am-5pm) Additional Comments How did you hear about us? Web search Word of Mouth Phonebook Mail/Post Card Referral Other The earth revolves around the ____? (3 characters required)