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	First name:	Last name:

	Street address:



	Town / City:	State / Province:

	Postal / Zip code:	Country:

	Email address: (Required)

	Daytime phone number:	Mobile phone number:


	Type of Move::



PBO - I will do my own packing:

PBC - aLocalVan will perform packing:
	Moving To (City or Area):

	List Items to be moved - For example, bed, dres, sofa, & 35 boxes...:

	Target Moving Date & General Notes regarding Move:

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