Details of Your Move

Company Name (If Applicable)
Your Name (If Applicable)
Your Email
Contact Phone Number
Address for the Service at Collection
Address for the Service at Delivery
Expected Date of Contact with Chess

Date of Service if Applicable

Uplift / Collection Date
Delivery Date
Services if Other

Declaration

Is anyone who lives at the service address currently under any form of self-isolation as the result of an order of any government authority or as the result of a recommendation of a health professional?
In the last 14 days, have you or anyone at the service address been in physical contact with anyone who has been diagnosed with the COVID-19 virus?
In the last 14 days, have you or anyone at the service address has been in physical contact with anyone who is in self-isolation due to the COVID-19 virus?
In the last 14 days, have you or anyone at the service address has been in physical contact with anyone who has recently visited any overseas country?
In the last 14 days, have you or anyone at the service address has been in physical contact with anyone who has recently visited or returned from Interstate?
In the last 14 days, has anyone at the service address experienced flu-like symptoms (sore throat, fever, tiredness, and cough) following overseas travel and/or physical contact with someone who has recently returned from overseas?
Consent and Accuracy