Full Name

Phone Number

Email Address

Origin Address (including city/town)

Destination Address (including city/town)

Piano Type

Brand

Model (if known)

Approximate Age

Approximate Weight (lbs)

Has the piano been moved before?

Known damage or structural concerns

Origin floor

Origin stairs

Origin stair count

Origin stair width if narrow

Origin elevator available?

Origin doorway clearance concerns?

Origin tight turns, low ceilings, or other obstacles

Piano currently located in

Destination floor

Destination stairs

Destination stair count

Destination stair width if narrow

Destination elevator available?

Destination doorway clearance concerns?

Destination tight turns, low ceilings, or other obstacles

Destination floor type

Piano currently climate-controlled?

After the move piano will be

Tuning referral requested after move?

Grand piano lid / leg disassembly required?

Piano bench included?

Piano cover / wrap provided by client?

Disposal of old piano requested?

Specific room or placement notes

Requested Move Date

Flexible on Date?

Any other information we should know

Printed Name

Date

Signature

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