REQUEST FOR US TO CONTACT YOU ABOUT YOUR CLEANING REQUIREMENTS

Please provide the following contact information so we may serve you better:

Title  Ms. Mrs. Mr. Dr.   First Name  

Last Name   

Home Address 

Address (cont.) 

City     Province      Postal Code:  

Work Phone   

Home Phone       Cell Phone      

E-mail  

Please tell us about the home you want cleaned:

Same Address as above? :Yes      No    

(If No, please give address with postal code)

Style & Size of Home: 

Single Level Two Storey Three Storey Bungalow Side Split Back Split Raised Ranch Multi - Level      Single Family Home Semi-Detached Duplex Townhouse Garden Home Apartment in older home Apartment (low rise) Apartment (high rise)           -1000 sq. ft. 1000 - 1800 sq. ft. 1800 - 2500 sq. ft. 2500 sq.ft. - 3300 sq.ft. 3300 - 4000 sq.ft +4000 sq.ft.

# of Occupants: Over 18 yrs old 1 2 3 4 5 6 6+   Aged 6 - 18 0 1 2 3 4 5 6 6+    Infant - 6 yrs 0 1 2 3 4 5 6 6+

# of Pets: Dogs 0 1 2 3 4 5+  Cats 0 1 2 3 4 5+    Birds  0 1 2 3 4 5+   Exotics:

Notes about Pets:

Occupants with Allergies.  Select 1 or more 

from list:

  None House Dust Mold & Fungus Perfumes Feathers Ragweed Grasses Certain Products Foods Nuts      Comments about allergies:   

Occupants with  Disabilities:No   Yes    Comments:

Have you used our service before?:     No      Yes, since 1997     

Have you ever had someone cleaning for you before?   No Yes       

How did you hear about us?:   From the Web From the Yellow Pages From one of your customers From the Radio From a flyer From a newspaper ad or article

How often do you want the service?             Once per week Once every 2 weeks Twice per week Three times per week Four times per week Daily

Approximately how many hours do you want per visit?      2.0 2.5 3.0 3.5 4.0 4.5 5.0 6.0 7.0 8.0 Not certain

Other duties required on a regular basis: None Laundry Ironing Picking up & tidying Changing bed Linens Washing dishes                         

While you are waiting for a permanent assignment of day and time, would you like to have temporary cleaning?:      Yes   No

Additional remarks:

Please rate our web site:  excellent     good    fair    poor

Suggestions to improve our site:

Upon receipt, we will contact you to:

• Answer any further questions you may have and discuss the amount of time that will be appropriate for your needs and budget.

Should you wish us to arrange service to your home, then we will:

• Set up a home visit to fine tune your specific requirements and complete any necessary paperwork.

• Set up temporary service, if a permanent slot is not immediately available.

( All information supplied by you is guarded with the strictest of confidence. 

No information is released to third parties for any reason whatsoever.)