*Required
fields in red
*Each
checklist must have at least
one box
checked.* |
Date:
|
Time:
|
Name:
|
Address:
|
City:
State:
Zip:
|
Day
Phone:
|
Evening
Phone:
|
|
PLEASE NOTE: WE
REQUIRE YOUR EMAIL ADDRESS IF YOU WOULD LIKE US TO RESPOND TO YOUR
REQUEST. Thank You!
E-mail
Address:
|
|
Service
Frequency: (Please
check one)
Weekly
Bi-Weekly
3 Weeks
4
Weeks
Monthly
Occasional
One-Time |
|
Areas
Needing Cleaning in
Your
Home:
Total
Square Footage:
|
| Total
Bedrooms:
Total
Bathrooms: |
Kitchen: (Please
check one or more)
Efficiency
Standard
Eat-In With Breakfast Nook |
Basement: (Please
check one)
Finished
Unfinished
N/A |
Does
Your Home Have: (Please
check one or more)
Office
Study
Den
Library
Family
Room
Living Room
Dining
Room
LR/DR
Combo
Foyer
Loft
Mud
Room
Other(s): |
|
| # of
Rooms with Wall-to-Wall Carpet With
Wood Floor |
| With
Linoleum/Tile
With
Quarry Tile |
| # of
Ceiling Fans |
|
How
did you hear about us?
|
May
we e-mail you special
promotions and
coupons?: (Please
check Yes or No)
Yes No |
Comments:
|