Name First Last
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Daytime Phone - (###) - ### ####
You may choose to provide only your preferred method of contact.
Evening Phone - (###) - ### ####
Email
Type of Service to be quoted (For a description of types click on "Cleaning Services" above.) Basic Clean Deep Clean Customer Preference Clean Regularly Scheduled Basic Cleanings
If requesting regularly scheduled basic cleanings, please select: Weekly Alternate Weeks Monthly
Date requested for first service:
First Date / MM / DD YYYY
Second Date / MM / DD YYYY
House Style One Story Two Story Three Story Split Level Apartment Condo
Square Footage
Number of Bedrooms
Number of Bathrooms
Other Rooms (please check all that apply). Kitchen Eat in Kitchen Dining Room Second Dining Room Breakfast Room Laundry Room Sun Room Living Room Great Room Family Room Play Room Bonus Room Den Home Office Library Foyer
Notes:
Flooring Types (Please check all that apply.) Carpet Hardwoods Vinyl Flooring Linoleum Marble Other Stone
Notes:
Countertops (Please check all that apply.) Vinyl Countertops Granite Wood Laminate
Notes:
Glass (Please tell us how many of each you have in your home.) Sliding Doors French Doors Storm Doors Windows
Notes:
Window Treatments (Please tell us how many of each you have in your home.) Mini Blinds Vertical Blinds Wood Blinds Shutters Heavy Drapes Valances
Notes:
Would you like us to clean the following?
Self Cleaning Oven
Manual Cleaning Oven
Refrigerator
Items to dust (i.e. furnishings, knick-knacks, pictures, items hanging on walls.) Sparce Average A Lot
Final five questions
Number of Inside Pets
Cats Dogs
Number of Children Living at Home
Number of People Who Smoke in the Home
What is the current condition of the home? Very Clean Fair to Average Needs a lot of attention
Referred By
Notes

Date requested for first service:

Would you like us to clean the following?

Final five questions