First Name
Last Name
Phone1
Phone2
Email
How do you prefer to receive confirmation of scheduled cleaning appointments? by phone by email
What type of cleaning? One Time Move-In Move-Out Initial
Preferred days and times for cleaning
House Address
City
State
Zip
# of pets
How many sets of stairs (total)
Pets are allowed Inside Only Outside Only Both
Pets are Friendly Not Friendly
Describe your pets (names and any other helpful information):
Is there street parking where you live?
Yes No
For emergency purposes only:
Fuse Box Location: Spare Vacuum Location:
Preferred Payment Method?
Cash Check Charge
Cleaning products
Bedrooms
XL - fits king size bed and furniture
Large - fits queen size bed and furniture
Medium - fits double or full size bed and furniture
Small - fits twin bed or crib and furniture
Bedroom #1 XL L M S
Bedroom #2 XL L M S
Bedroom #3 XL L M S
Bedroom #4 XL L M S
Bedroom #5 XL L M S
Size of bathroom
XL – has separate shower and tub plus toilet and sink(s)
L – has a combination shower and tub plus toilet and sink
Medium – has a shower OR a tub plus toilet and sink
Small – has only a toilet and sink
Bathroom #1 XL L M S
Shower and/or sink area has tile yes no
Bathroom #2 XL L M S
Shower and/or sink area has tile yes no
Bathroom #3 XL L M S
Shower and/or sink area has tile yes no
Bathroom #4 XL L M S
Shower and/or sink area has tile yes no
Kitchen
XL – larger kitchen with plenty of room for an island, prep sink, etc.
Large – average sized kitchen for a house, may have room for an island
Medium – larger apartment sized kitchen
Small – smaller apartment sized kitchen
XL L M S
Living Room
XL – larger, ‘entertaining’ sized living room, room for a couch, side chairs, coffee table, TV and lots of other furniture
Large – Average sized living area for house, room for couch, chiar coffee table and TV
Medium – larger apartment sized living area or living room for a smaller house, room for a couch, chair and not a lot of other furniture.
Small – apartment living room with couch and not a lot of other furniture.
XL L M S
Dining Room
XL – larger, ‘entertaining’ sized dining room, room for a table plus lots of other furniture
Large – Average sized dining area for house, room for table, plus one or two pieces of other furniture
Medium – smaller dining area for a house, only room for a dining table
Small – eating nook or apartment dining area
XL L M S
Additional Services Clean small countertop apppliances Clean the dish drain Detail clean kitchen items such as burner knobs, dishwasher screws
Remove mildew stains from grout
Spot clean telephones
Clean fingerprints on doorway trim, doors and light switch covers
Clean windows and sliding doors
Dust blinds (may require a blinds cleaning specialist)
Change towels and/or bed linens
Remove trash and recycling; clean bins
Sweep the porch and front steps
Optional Sub-contracted Services Carpet cleaning Roof cleaning Window washing
Gutter cleaning
Pressure washing
Professional organizing for home or office
Moss control
Window blinds cleaning
Wall washing
Power washing
Junk and debris removal
Crawl Space cleaning
Staging (professional redecorating)
Where did you hear about us?
Yellow Pages Banana Pages Biz-X Returning Client Other Cleaning Company Company Name: Word of Mouth Source: Other Source:
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