Just complete this form. Click on Submit when ready to send.

Date of Move:	*mm/dd/yyyy
Shipper:
Old Address:
City:
New Address:
City:
Home Phone:	*###-###-####
Work Phone:	*###-###-####
E-mail:
Crew Leader:
Crew Members:

In Order to maintain the high standard of quality service that Midwest & Storage, Inc. is known for, we would appreciate your cooperation in answering the following questions:

What time did the crew arrive?
What time did they depart?

Did the crew work efficiently together?

Yes
No

Were the men courteous and helpful?

Yes
No

Were the premises cleared of debris before departure?

Yes
No

How would you rate the handling of your goods?

Excellent
Good
Fair
Poor

Were your goods blanket wrapped in your home?

Yes
No

Was your estimate done in house or by phone?

House
Phone

Was it within a reasonable range?

Yes
No

Would you recommend us to family and friends?

Yes
No

Would you allow us to use your name and phone number (or e-mail address) on our reference list?

Yes
No

Would you take a moment to tell us anything you feel would help improve service for our customers?