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                                      Name:  
                                     
                                      E-mail:  
                                     
                                      Telephone # @ work: 
                                     
                                      Telephone # @ home: 
                                     
                                      Address: 
                                     
                                      City: 
                                     
                                       Zip code:
                                     

                                      Approx square footage: 
                                     
                                      Number of bedrooms:    
                                     
                                      Number of bathrooms:         
                                     
                                      Number of levels:    
                                     

                                      Clear glass shower doors?  
                                         yes    no
                                      Family room?  
                                         yes    no
                                     Types of flooring?    
                                          carpeting
                                          hardwood
                                          stone
                                          vinyl
                                          other
                                       Window blinds/shutters? 
                                         yes     no
           
                                       Kitchen:
                                       Wood finish cabinets?    
                                         yes    no
                                       painted? 
                                         yes     no
                                       white?  
                                         yes     no
                                       Floor type?
                                         vinyl
                                         wood
                                         ceramic tile
                                         other
                                      Self-cleaning oven?      
                                         yes     no
                                      Stainless steel appliances?  
                                         yes     no
  
                                       Pets in the home?  
                                         yes     no

                                       If yes, what are they?   
                                       

                                       Special instructions about 
                                       pets (must stay inside etc.):   
                                      
                                               
                                        Number of people
                                        in your household?     
                                       
 
                                        How did you hear of us?  
                                        Internet Yellow Pages Word of mouth Other  

                                         If Internet--what search engine?  
                                        

                                         How frequent a service
                                         are you interested in?   
                                        Weekly Bi-weekly Monthly Occasional One-Time

                                         Requested cleaning day?
                                         Monday Tuesday Wednesday Thursday Friday Saturday

                                         If a one time request, 
                                         what is your preferred  date? 
                                       
                       
                                         Preferred method of contact:  
                                        Telephone E-mail