*Required fields in red
*Each checklist must have at least one box checked.* |
Date:
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Time:
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Name:
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Address:
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City:
State: Zip: |
Day Phone:
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Evening Phone:
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PLEASE NOTE: WE REQUIRE YOUR EMAIL ADDRESS IF YOU WOULD LIKE US TO RESPOND TO YOUR REQUEST. Thank You!
E-mail Address:
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Service Frequency: (Please check one)
Weekly Bi-Weekly 3 Weeks
4 Weeks Monthly Occasional One-Time |
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| Areas Needing Cleaning in Your Home:
Total Square Footage:
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| Total Bedrooms: Total Bathrooms: |
Kitchen: (Please check one or more)
Efficiency Standard
Eat-In With Breakfast Nook |
Basement: (Please check one)
Finished Unfinished N/A |
Does Your Home Have: (Please check one or more)
Office Study Den Library
Family Room Living Room Dining Room
LR/DR Combo Foyer Loft
Mud Room
Other(s): |
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| # of Rooms with Wall-to-Wall Carpet With Wood Floor |
| With Linoleum/Tile With Quarry Tile |
| # of Ceiling Fans |
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How did you hear about Erie House Cleaning®?:
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May we e-mail you special promotions and coupons?: (Please check Yes or No)
Yes No |
Comments:
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