Personal Information

Last Name First Name Initial  
Address Town Zip  
Phone Cell Email  

Home Information (fill in X or type in information)

Type   Condo Townhouse Single Family Apartment Number of Floors
Size of Rooms   Small Average Large      
Cleaning Frequency   Weekly Bi-Weekly Monthly One-Time  
Children or Pets   Children Dog(s) Cat(s) Other
Number of Rooms

Floor Type

Kitchen Tile Vinyl Carpet Wood
Full Bathrooms Tile Vinyl Carpet Wood
Half Bathrooms Tile Vinyl Carpet Wood
Living Room Tile Vinyl Carpet Wood
Den/Family Room Tile Vinyl Carpet Wood
Dining Room Tile Vinyl Carpet Wood
Bedrooms Tile Vinyl Carpet Wood

Other Information (Optional)

Current Cleaning Service  
Do you want us to change bedroom linens   Yes No
(If so please leave on beds)
Do you want us to change bath towels   Yes No
(If so please leave out)
Blinds or other special services:  
Comments: