| First Name: | |
| Last Name: | |
| Address Street 1: | NO P. O. BOX! |
| Address Street 2: | |
| City: | |
| State: | |
| Zip Code: | (5 digits) |
| Daytime Phone: | |
| Evening Phone: | |
| Email: | |
| What type of cleaning is needed?: | |
| Additional tasks | Window Washing |
| | Wipe blinds |
| | Inside of Oven & Refrigarator |
| | Wipe down walls |
| | Wipe down woodwork |
| | Laundry (If you have washer machine at home) |
| | Organizing |
| | Dishes |
| | Window Washing |
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| How often does your home need to be cleaned? (Recurring service): | |
| When do you need this service to begin?: | |
| What is your budget per visit?: | |
| Bathrooms: | |
| Bedrooms: | |
| Enter the Square Footage for the House that needs Cleaning: | |
| What type of residence needs cleaning?: | |
| How did you hear about GHOCS?: | |
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