First Name: Last Name: Address: City: State: Zip : Phone: Phone (bus or cell): Email: Please tell us how your heard about Us. Internet Referred NewsPapers Radio TV Spot PREFERRED CLEANING TIME AND DATE: Day of week: Monday Tuesday Wednesday Thursday Friday Saturday Sunday or if you require a specific date, enter it) Time of Day: Early Morning Late Morning Mid Day Early Afternoon Late Afternoon CARPET TO BE CLEANED Living: 0 1 2 3 4 Dining: 0 1 2 3 4 5 Hall: 0 1 2 3 4 5 Family: 0 1 2 3 Kitchen: 0 1 2 3 4 Foyer: 0 1 2 3 Great: 0 1 2 3 Utility: 0 1 2 3 4 Staircase: 0 1 2 3 Office: 0 1 2 3 4 Master Bedroom: 0 1 2 3 4 Landing: 0 1 2 3 4 Den: 0 1 2 3 4 Bedroom: 0 1 2 3 4 5 6 7 Bathroom: 0 1 2 3 4 5 6 Study: 0 1 2 3 4 5 Walk-In Closet: 0 1 2 3 4 5 Other: 0 1 2 3 4 5 6 7 Areas over 200 sq ft: 100 sq/ft 200 sq/ft 300 sq/ft 400 sq/ft 500 sq/ft 600 sq/ft 700 sq/ft 800 sq/ft 900 sq/ft Areas to protect: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Tell us about any areas of concern (spots, stains, urine spots, etc.) UPHOLSTERY TO BE CLEANED Sofa: 0 1 2 3 4 5 Chair: 0 1 2 3 4 5 6 7 8 Sectional (# of pieces): 0 1 2 3 4 5 6 7 8 9 Loveseat: 0 1 2 3 4 5 6 7 Ottoman: 0 1 2 3 4 5 Looseback Cushions: 0 1 2 3 4 5 6 7 Recliner: 0 1 2 3 4 5 Dining Chair: 0 1 2 3 4 5 6 7 8 9 10 11 12 Loose Pillows: 0 1 2 3 4 5 6 7 Tell us about your furniture (condition, fabric type: cotton, silk, wool) AIR DUCT Type: Residential Commercial Number of Openings: Count the number of openings per room. (Include Cold Air Returns.) Deodorizer: Yes No Sanitize: Yes No ADDITIONAL SERVICES Area Rug Oriental Rug Vehicle Interior Tile & Grout Cleaning Tile & Grout Coloring Tell us about additional services you need (Tile & Grout Cleaning, Pet Odor, etc) When is the best time to call? Time: Anytime 8am-9am 9am-12pm 11am-2pm 1pm-4pm 3pm-6pm 5pm-8pm Day: Monday Tuesday Wednesday Thursday Friday Saturday Sunday