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*First / Last Name:
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 Day Phone: (xxx-xxx-xxxx)
 Evening Phone: (xxx-xxx-xxxx)
*From City:
*From State:
 From Zip:
*To City:
*To State:
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*Approx. date of move:
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12183 W. Linebaugh Avenue  |  Tampa, Florida 33626  |  1-800-876-6839
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