*Required
fields in red
*Each checklist must have at least one box
checked.* |
Date:
|
Time:
|
Name:
|
Address:
|
City:
State:
Zip:
|
Day
Phone:
|
Evening
Phone:
|
Best Time to Call You During Day:
(Please select
AM or PM)
AM PM |
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
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 Aurora
House Cleaning by Mountain
MaidsŪ?:
|
May we e-mail you special promotions and
coupons?: (Please check Yes or No)
Yes No |
Comments:
|