Qualex Inc - Online Residential Delivery Estimate Request Form

RESIDENTIAL DELIVERY ESTIMATE REQUEST FORM

Pick-Up Information

Blanket Wrap Cartoned

Name:

Address:

City/State/Zip Code:

Phone:

Contact:

Description

Brief description of work to be done:

Pick-up Information

Pieces/Cartons:

$ Value:

P.O(s):

Weight:

Cube/Truck Space:

Residential Delivery Information

Description of items to be delivered to Residence

PCS	Description	Weight/lb.

Bill To Information

Name:

Address:

City/State/Zip Code:

Phone:

Contact:

E-mail:

Email estimate to:

Fax estimate to:

Type of Payment

C.O.D.:

Prepay:

Visa/Mastercard:

On Account:

(If On-Account, please include account name if different and Qualex Account No.)

Account Info:

OUR SERVICES

Qualex Inc.
3541 Union Pacific Ave.
Los Angeles CA, 90023
Toll free: (800) 268-7496
Phone: (323) 268-7496
Fax: (323) 268-4535