* indicates required fields    *Name:   *Address:   Contact number:   *Email address:   Square footage:   Bedrooms:  1  2  3  4   Bathrooms:  1  2  3  4   Appliances cleaned interior?: Oven Fridge Both   Interior windows washed?:  Yes  No   Baseboards wiped?:  Yes  No   Window sills wiped?:  Yes  No   Walls spot cleaned?: Yes No   Dust light fixtures?:  Yes  No   Garage swept?:  Yes  No   Blinds cleaned? If so, how many?:   *Where did you hear about us?:   Requested day of cleaning:   Condition of Home:  Poor  Fair  Good  Excellent   Preferred Method of Contact: Email Telephone   Comments:   Amount Budgeted for Cleaning:

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