Initial Questionnaire

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We will review your submission and schedule a time for a complimentary walk-through. Thank you for taking the time to answer the questions!
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1.How many bedrooms?*

Studio (Starting at $110)1 (Starting at $130)2 (Starting at $150)3 (Starting at $170)4 ( Starting at $200)5+ ( Starting at $230)
2. How many bathrooms?*

11.522.53+
3. Do you own pets?*

YesNo
If yes, what pet(s) do you own? (Dog, cat)
5. How did you hear about us?*
If referred, please mention their name:
6. Frequency of Maid In Luzerne’s services?*
How often would you like us to service you?
7. What scents/smells do you like, if any? (Ex: Lavender, lemon, floral)
Feel free to leave blank, if you aren’t picky!
8. What scents/smells do you dislike, if any? (Ex: Vanilla, orange, cinnamon)
Feel free to leave blank, if you aren’t picky!
9. Do you have any known allergies?*

YesNo
If yes, please list all allergies:
10. Type of service?*
11. What clean option best suits your needs?*
Should be Empty:

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