Reusing furnishings, Renewing lives in the Raleigh area

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Urgent & Ongoing Needs

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The Green Chair Project

For Partner Agency Use Only

Client Order Form

Your Info

Client Info

* Agency Name

* Agency Contact

* Email

* Phone

Additional Information

Needs Assessment

Approximate size of home

Others in Household

Color preferences of furniture (not guaranteed)

Statement of client need

Client Agreement (Client to read and sign)

Client must agree to the following 4 statements

1. Client must be present at pick up with check from agency, cash or money order

2. All furnishings must be picked up at once

3. Failure to pick up at the scheduled time will result in a forfeited opportunity

4. Rescheduling only permitted with 24 hours advance notice.

Client E-Signature

Client Pick Up Time

Saturday pick up: Month

Date

Time

Request for week-day pick-up time (Month/Date/Time) *You will receive confirmation if this request can be met

Additional Information

Item and Quantity

Couch - (Points:20)

Dining Table/4 Chairs - (Points:20)

Breakfast Table/2 Chars - (Points:15)

Kitchen Package/4 - (Points:10)

Kitchen Package/2 - (Points:6)

Upholstered Chair W/ Ottoman - (Points:10)

Recliner - (Points:10)

Dresser W/ Mirror - (Points:10)

Upholstered Chair - (Points:8)

Desk - (Points:8)

Side Table W/ Lamp - (Points:7)

TV - (Points:6)

Microwave - (Points:6)

Coffee Table - (Points:5)

Dining/Side Chair - (Points:2)

Floor Lamp - (Points:2)

Small Appliances - (Points:1)

Accessories - Specify preference - (Points:1)

Client Order Totals

Item Quantity

Total Points (multiply each item quantity above by the number of points indicated and add together)

Client Order Charge

$50.00 for 1-25 points

$100.00 for 26-50 points

$150.00 for 51-75 points

Send Request

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