Cleaning Request Form (Website Form)
Type of Service
*
NDIS Cleaning Service
Cleaning Service
Client Details
Name
First Name
Last Name
Billing Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Client Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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NDIS Participant Details
Please skip this section if you are not an NDIS participant.
NDIS Participant Number
NDIS Item Code
NDIS Funding Management Type?
Self-Managed
Plan-Managed
Birth Date
-
Day
-
Month
Year
Date
To make sure the service is appropriate and safe, are there any support needs or risks we should be aware of during the clean? For example: Chemical sensitivities or allergies to foods.
Important:
Unfortunately, we do not accept NDIA-managed Clients. We are very sorry for the inconvenience.
Represenetative's Details
First Name
Last Name
Represenetatives Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Representative's Email
example@example.com
Plan Manager Details
Manager Name
First Name
Last Name
Plan Managers Invoicing Email
example@example.com
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Property Details
Number of levels?
Please Select
1
2
3
4
Number of Bedrooms?
Please Select
1
2
3
4
5
6
7
Number of Bathrooms?
Please Select
1
2
3
4
5
6
7
Number of Living Areas?
Please Select
1
2
3
4
Number of Seperate Toilets?
Please Select
1
2
3
4
Do you have a laundry?
Please Select
Yes
No
Last Professional Clean?
Please Select
Week
Fortnight
Month
3 Months
Never
Parking Availability?
Please Select
My driveway
Free Street Parking
Paid Street Parking
Paid Carpark
Property Access
Please Select
Hidden Key
Lockbox
Door Code
Someone Will Be Home
Set Of Keys
Garage Remote
Other
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Cleaning Service Details
Please choose a prefered date and time unless you have already booked, you will recieve this section prefilled.
Appointment
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Terms & Conditions
Please kindly read the terms and conditions.
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Submit
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