Furnishings Request Form (revised-in progress)

Make It Home

a Furniture Bank serving Northern California from Novato, CA Office tel: (415) 870-1998 EXT. 203
Furnishings Request Form

$450 Service Fee associated per order (Delivery Fee separate)
Important Information Before You Begin
A $450 service fee is required per order. (Delivery fee billed separately.)
All fields marked with * are required.

If you are requesting furnishings for multiple units or a community space, please contact
services@makeithomebayarea.org for special pricing before submitting this form.

Preparing for a Successful Delivery

A video tour of the entry and entire residence is strongly recommended and may be emailed to services@makeithomebayarea.org with the client name in the subject line.

Please confirm that the unit can accommodate the furniture requested.

Returns Policy

A $200 return fee will be charged for items that must be taken back due to:

- Items being too large for the space
- Too many items requested
- Client preference changes
- Items returned because they are gently used
- Client already possessing requested items

This fee helps offset additional moving and labor costs.
Date of submission

YearMonthDay

Name of Client*

Client First NameClient Last Name
Head of Household identifies as:*
Options: Male, Female, Non-Binary, Other
CLIENT Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Building Number in complex if applicable:
building number in complex if applicable
County*
We have two locations, San Rafael serves: Marin, San Francisco and Sonoma counties. Walnut Creek serves: Alameda, Contra Costa Napa, & Solano counties. Other counties will be served from the most efficient location.
Reason for referral (check all that apply)*

RefugeeHomelessnessDomestic ViolenceChild Welfare CaseCurrent/Former Foster YouthEmergency Loss (Fire/Water/Natural Disaster)VeteranNone of the above
If "refugee" was checked above, please note the country of origin: country
Head of Household Race *
Head of Household Ethnicity*
Client annual income range (for data collection and grant purposes)*

$0-25,000$26,000-50,000$51,000-75,000$76,000-100,000above $100,000Unknown
Does client have a phone number we can use to contact them?*

YesNo
Client Phone Number
Please enter a valid phone number.
Client will reside in:*

SROStudio1 Bedroom2 Bedroom3 BedroomOther
Floor*

Ground/1st2nd3rd4th5th6th7thOther
How many stairs to front doorway?
how many stairs will the movers need to ascend/descend to enter the front door?
How many interior stairs are within the apartment?
Is there an elevator?*

YesNo
Does client have any physical disability/ limitations? *
Does your client need any items for religious or cultural purposes for comfort and dignity?
If yes, please include notes on ANY physical limitations or considerations of residents or circumstances that we should be aware of?
Physical considerations
Please tell us how many adults live in the household?
Enter total adults including client
Please tell us how many children live in the household?
Enter total children under the age of 18

Please tell us about the children (if any) living in the space:

	Age	Gender	special interests (Spiderman, basketball, unicorns, etc.)
Child
Child
Child
Child
Child

Considerations for the space and client

Please give us as much information as possible so that we can provide the best items for your client.
COLOR CONSIDERATIONS*

Client prefers NEUTRAL selectionsClient prefers COLORFUL selectionsClient prefers a mix of COLORFUL & NEUTRAL selectionsClient does not have a preference
Please provide information about the space or more specificities as to the styles of furnishings your client likes and we will do our best to accommodate them:*

Agency Name (if this is your first time using us type "other")*
Agency Name (specify if "Other")
Program Within Agency (if applicable)
Case Worker's Name*

Case Worker's First NameCase Worker's Last Name
Case Worker's Office Phone*
Please enter a valid phone number.
Case Worker's Cell Phone*
Please enter a valid phone number.
Case Worker's Email Address*
example@example.com
Supervisor's Email Address (will be cc'd on this submission)
example@example.com
Privacy Policy and Terms of Service*

I agree to receive transactional SMS from Make It Home related to my account, including alerts, notifications, and security messages. Providing a phone number alone does not constitute consent. Message frequency varies. Message and data rates may apply. Reply STOP to opt out or HELP for help.I agree to the Privacy Policy and Terms of Service linked below.
Link here to Privacy Policy and Terms of Service
POLICIES and PROCEDURES
Make It Home Non-Liability Acceptance*

MIH shall not be liable for special, incidental or consequential damages resulting from damages caused by or resulting from insects, moths, vermin, ordinary wear and tear, dust, or gradual deterioration.
USED Furnishings and NO Returns Policy acknowledgement *

I have explained to my client that the furnishings are USED and that MIH does not accept returns. My client understands the furnishings are NOT new, but are gently used and vetted to the best of Make It Home's abilities. If my client does require the mover to take items back, regardless of this policy, the agency will be charged $200 restocking fee.
Cancellation or Rescheduling Policy*

I understand that a TWO business day minimum is required for cancellation or rescheduling of a scheduled delivery. If the cancellation/rescheduling is outside the two day minimum, there will be no charge. If the cancellation/rescheduling is within two business days, the agency will be billed $250. If the cancellation/rescheduling is the day of scheduled delivery, the agency will be charged $675 for mover fees.
No-Show Fees Acknowledgement*

If Make It Home arranges moving services for an agency and there's a no-call/no-show, the agency will be charged $675 for mover fees.
Approval Authority Signature in acknowledgement of the above policies regarding liability, used furnishings, no returns policy, cancellation/rescheduling policy and no-show fees. *
Delivery Services & Payment

(Fees apply only if Make It Home provides delivery. We do not accept payment directly from clients.)
Please select Agency Pick Up or Make It Home Delivery*

Agency will arrange pickup from the Make It Home warehouse and deliver to the client. Make It Home will notify the agency by email when items are ready for pickup.Agency would like Make It Home to provide delivery and will be invoiced by Make It Home. *Delivery Fee Chart Below*
DELIVERY DATE: We need a minimum of THREE (3) business days to complete your request.

Requests before this date cannot be accommodated.
DELIVERY DATE/PICK UP DATE 1st Preference. Please note this is not guaranteed. *

MonthDayYear
1st choice delivery date
DELIVERY DATE/PICK UP DATE 2nd Preference. Please note this is not guaranteed. *

MonthDayYear
2nd choice delivery date
IF YOU ARE COORDINATING YOUR OWN PICK UP YOU MUST PROVIDE YOUR MOVERS CONTACT INFO:

First NameLast Name
Moving Company Phone Number
Please enter a valid phone number.
Delivery Fee Acknowledgement*

I understand, if the agency does not take care of moving services, and requests that Make It Home contracts with an outside provider for moving services, there will be a furniture delivery/set-up fee (see rates in chart below). Although returns are HIGHLY discouraged, if there are any returns, there will be an additional delivery cost of $200 for additional mover fees.

Items Needed for the Household: All orders based upon availability; please enter quantities below.
Please select NEEDED BEDS option:*

Provide ONE Queen Bed (inclusive of platform/frame and bedding)Provide ONE Queen Bed and ONE Twin Bed (inclusive of platform/frame and bedding)Provide ONE Twin Bed (inclusive of platform/frame and bedding)Provide TWO Twin Beds (inclusive of platform/frame and bedding)NO beds are needed for this household
Please select any of the following children's special beds (WE RARELY HAVE THESE ITEMS but if we do we are happy to provide, no additional fee):

cribcrib mattresstoddler bedtoddler mattressportable cribtrundle bedbunk bed
EXTRA QUEEN BEDS with frames REQUESTED:
will incur additional expenses of $415 each
EXTRA TWIN BEDS with frames REQUESTED:
will incur additional expenses of $250 each
Dressers are available, maximum ONE per household due to limited availability. Please select one option:

One single-width dresserOne double dresser

Items requested:

	Quantity
Kitchen Table
Kitchen Chair (max 6)
Sofa (max 1)
Lounge Chair (dependent on # of family members)
Artwork
Bar stool (42" high countertop) (max 4)
Counter stool (36" high countertop) (max 4)
tall BOOKSHELF (max 1)
low BOOKSHELF (max 2)
Coffee Table (max 1)
Desk (max 1)
Desk chair (max 1)
floor LAMP (Limited Availability) (max 1)
table LAMP (max 4)
Mirror (max 2)
Nightstand (max 3)
Rug Living Room (note size in special requests below)
Rug Bedroom (note size in special requests below)
Side Table (max 3)
TV Stand
Outdoor Living Furniture (limited availability)

Can client accommodate larger furniture items?*

	Yes	No	N/A
If requested, can sofa be wider than 7 ft?
If requested, can dining table be wider than 5 ft?

Rug sizes if rugs have been requested:

Kit request

	Yes
Bath Kit
Cleaning Supplies limited availability
Kitchen Essentials Kit (cookware, pots, pans)
Dining Kit (plates, bowls, silverware, glassware)

Special Requests: Updated Monthly to reflect current inventory. Note these items are not guaranteed, they will be included only when we have them in stock.

	Yes
Microwave
Toaster
Toaster Oven
Air Fryer
Blender
Electric Hand Mixer
Rice Cooker
Waffle Maker
George Foreman Grill
Crock Pot
Standard Pot Coffee Maker
Single Pod Coffee Maker
Coffee Grinder
Electric Can Opener
Cast Iron Pan/Skillet
Large Roasting Pan
Kitchen/Bathroom Trash Cans
Iron
Ironing Board
Electric Water Heater
Hair Dryer
Shower Curtain
Shoe Organizer
Box of Decorative Accessories

Special Requests, Delivery Notes or Special Instructions (if none, type none):*
Date/Time of Submission

MonthDayYear
Date
Hour MinutesAM/PM Option

OFFICE USE ONLY / CONFIRM PAYMENT

PayPal payment selected / Payment receivedInvoice payment selected / Invoice sentInvoice payment receivedCoupon code usedOther (explain):
How would you like to pay the $450 service fee?*

Pay now via PayPal or credit/debit cardPrepayments covers negotiated fees only (does not cover additional beds)I have obtained permission from Make It Home to be invoiced
If you selected "I have obtained permission from Make It Home to be invoiced", my code is:
If you would like us to invoice a 3rd party, please provide the invoicing details below. Include a name, company, AND email address.
Send invoice to:

First Name (for invoice)Last Name (for invoice)
Company/Agency Name
3rd Party Company/Agency
Send invoice to (Email address):
example@example.com
Send second copy of invoice to (Email address):
example@example.com

Check the box below to make payment via PayPal or debit/credit card now. Note that you will receive an invoice receipt via email on submission.

Make It Home Service Fee

$450.00

Additional twin mattress & frame fee

$250.00 Quantity

Additional queen mattress & frame fee

$415.00 Quantity

Enter coupon

Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty:

Make It Home

Furnishings Request Form

Considerations for the space and client

POLICIES and PROCEDURES

Delivery Services & Payment

DELIVERY DATE: We need a minimum of THREE (3) business days to complete your request.