Housewares Order Form

Company

Consultant Name

Consultant Email

Insurance Company

Guest Name

Claim ID #

Guest ID #

Phone #

Address

Unit/Apt#

City

State

Zip code

Is this address inside a gated community?

YesNo

Landlord Name

Landlord Phone

Lease Term

2 months3 months4 months5 months6 months

End of Agreement Date

Number of Adults

123456

Number of Children

0123456

Delivery date needed

King Bedsets

01 set2 sets3 sets4 sets

Queen Bedsets

01 set2 sets3 sets4 sets

Full Bedsets

01 set2 sets3 sets4 sets

Twin Bedsets

01 set2 sets3 sets4 sets

Full Bathrooms

01234

Half Bathrooms

0123

Extra Towel Kits

0123

Number of Place Settings

0 Place Settings4 Place Settings8 Place Settings12 Place Settings16 Place Settings

Kitchen PackageCleaning PackageIron and Ironing BoardSwiffer SweeperHand MixerBlenderKeurig Coffee MakerPet Package (specify below)Crock PotTea KettleAsian KitchenToaster Oven

Pet Package

Special Requests

After verifying all information is correct, please check this box and press the submit button below.