*Required fields in red
*Each checklist must have at least one box checked.* |
Date:
|
Time:
|
Name:
|
Address:
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City:
State:
Zip:
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Day Phone:
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Evening Phone:
|
Best Time to Call You During Day: (Please select AM or PM)
AM
PM |
E-mail Address:
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Service Frequency: (Please check one)
Weekly Bi-Weekly 3 Weeks
4
Weeks Monthly Occasional One-Time |
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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
Garage Mud Room
Other(s): |
|
| # of Rooms with Wall-to-Wall Carpet
With Wood Floor |
| With Linoleum/Tile
With Quarry Tile |
| # of Ceiling Fans # of
Cathedral Ceiling Areas |
Windows Need Cleaning: (Please check one)
Inside Outside Both
N/A |
|
How did you hear about Maid to
Perfection®?:
|
May we e-mail you special promotions and
coupons?: (Please check Yes or No)
Yes No |
Comments:
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