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Please tell us about yourself:

Your name:
Property address:
Suite or Apt. #:
City / State / Zip:
Home phone:
Work phone:
Ext#:
Cellular:
E-mail address:
I would like to:
Requested service date:	First available date Schedule me on this date: Don't schedule me yet
Please confirm via:	E-mail Telephone Both

Please tell us about your home:

Number of bedrooms:
Number of bathrooms:
Number of levels:
Do you have pets?:
Type of pet:
Number of pets:
Please check the type of service requested:	Basic cleaning only Basic cleaning with optional services
Please specify desired optional services:	Oven Cleaning: $20.00 Refrigerator Cleaning: $20.00 Hand Polish Furniture: $9.50 each piece Vacuum Furniture: 10.00 each piece Fireplace Cleaning: $20.00 Window Cleaning: $4.50 ea. (inside only) Number of windows to be cleaned?

Payment Information:

Type of payment:	Cash — Check — Credit Card — Money Order Other We Guarantee our cleaning 100%. If you are not satisfied with our services, call us within 24 hours, otherwise, we will understand that all services have met your expectation and we will not consider your complain. All new services are to be paid in full prior to the date of service. Accept Terms and conditions We request that all customers give 24 hour notice for all cancellations. Cancellations without this advance notice will be subject to a $10.00 surcharge. If we arrive at the home and you cancel once we have made the trip out there, we reserve the right to charge a $25.00 trip fee. Accept Terms and conditions After the first cleaning, customer will provide all supplies. In case VIA Maid Services® has to provide the supplies, a charge of $ 5.00 extra will be add to your cleaning fee. Accept Terms and conditions
I have read FAQ, Services and understand the terms and conditions of your pricing and agree to pay accordingly for services rendered.

Additional Requests: