Your Contact Information:
Company Name:
Contact Name:
Position:
Address:
City:
State:
Zip:
Phone:
Email:
 
Tell us what you need:
Type of Facility:   If other:
Frequency of Service:  
Other
Number of Offices:
Number of Windows:
Sq.Ft of Building:
Sq. Ft. of Vinyl:
Sq. Ft. of Ceramic Tile:
Sq. Ft. of Concrete:
Sq. Ft. of Linoleum:
Sq. Ft. of Other Flooring:      Type:
Area to be buffed:     Frequency:
Area to be waxed:     Frequency:
Empty all waste receptacles: Yes    No
Dust Mini-blinds & A/C Vents: Yes    No
Dust & Wipe tables Yes    No
Clean Glass Doors & Partitions Yes    No
Dust Picture Frames & Wall Hangings Yes    No
Vacuum Carpet: Yes    No       Sq. Ft. of Carpet:
Clean & Disinfect Restrooms: Yes    No      Number of stalls:
Carpet Cleaning Yes    No
Strip & Wax Floors Yes    No      Frequency:
Area to be stripped
Would you like to include stripping and waxing on the bill, or be billed separately on an "as needed basis"?

Yes - Include it in the Bill    No - Bill separately as needed
Who will provide the supplies: Clean Choice    Customer

Is there anything else you would like to let us know?