| First
Name*: |
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| Last Name*: |
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| Address*: |
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| Apartment,
Condo
or Suite: |
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| City*: |
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| State*: |
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| Zip*: |
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| Phone Number*: |
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E-mail
Address*: |
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Preferred method of contact? |
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Service Requested*: |
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| If Other, please specify: |
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When would you like to begin service?* |
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Frequency of Service*: |
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| How did you hear about our services?* |
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| Maid Service
Customers Only. |
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Bedrooms: |
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| Full
Bathrooms: |
Half Bathrooms:
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Which additional rooms would you like cleaned? |
Breakfast
RoomFamily
Room
Home
Gym
Library/OfficeMedia
Room
Other |
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Basement: |
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Additional Services Needed:
Cabinets - $30, Both Refrigerator and Oven - $40
or $25 separately |
Interior
Oven
Interior
Refrigerator |
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What type of flooring do you have in your home? |
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Would you prefer the team use your personal vacuum? |
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Will your home be empty of furniture when the team
arrives to clean? |
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How would you rate the current cleanliness of your home? |
(1 Very Soiled - 10
Very Clean) |
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Will you remove clutter before the team arrives to begin
cleaning? |
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How many people live in your home? |
Adults/Teenagers
Small Children |
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Do you have pets? |
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What is the approximate square footage of your home? |
If you are not sure, you can use
www.zillow.com. |
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Is parking available at your home? |
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How will the team access your home? |
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When was the last time you hired a professional
cleaning or laundry company? |
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When are you available for a FREE in-home
consultation? |
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Special Maid Service or
Laundry Instructions:
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Would you like to receive e-mails
announcing new services, promotions or general information
from Your Pampered Home? |
Yes
No |
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| If given the opportunity to choose your own price
for maid service, what amount do you think is fair? |
$
.00 |
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| By clicking the Submit Application
button below, I agree to have a representative from
Your Pampered Home contact me using my contact information
listed above to discuss services offered. |
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