Intake Form

1
Main Contact Name* This field is required.
First Name
Last Name
2
Title* This field is required.
Homeowner
Contractor
Interior Designer
Personal Assistant
Other
3
CompanyIf applicable
4
What is the best phone number to reach you?* This field is required.
Please Select
Please Select
Mobile
Home
Work
Which number is this?
5
Alternate phone number (if applicable):Click 'Next' if not applicable.
Please Select
Please Select
Mobile
Home
Work
Which number is this?
6
Email* This field is required.
example@example.com
7
How did you hear about Fox Chandelier Cleaning LLC?* This field is required.
Facebook
Instagram
Internet
Yelp
Van
Other
8
If you chose 'other', please tell us how you heard about Fox Chandelier Cleaning LLC.
9
Project NameIf applicable, please list project name, client name or sidemark (S/M)
10
Job Site Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
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Austria
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Belgium
Belize
Benin
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Bolivia
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Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
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Cook Islands
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Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
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Egypt
El Salvador
Equatorial Guinea
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Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
11
Billing AddressIf different than Job Site Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
12
Do you have a deadline?* This field is required.
YESNO
13
By what date do you need the work to be completed?
Date
Year
Month
Day
14
How many different fixtures would you like cleaned?* This field is required.If you have two or more identical fixtures in the same room, count as one fixture. Example: Two identical wall sconces in your dining room would count as one fixture.
1
2
3
4
5
6
More than 6
15
To your knowledge, have any of the fixtures been exposed to cigarette smoke?* This field is required.
YesNo
16
Fixture 1

(Please answer the following questions about Fixture 1. Click 'Next' to begin.)
17
Is this an interior or exterior fixture?* This field is required.
Interior
Exterior
18
What floor is this fixture located on?* This field is required.Ex. 1st floor, 2nd floor
19
What room is this fixture located in?* This field is required.Ex. dining room, living room, kitchen
20
What type of fixture is this?* This field is required.
Chandelier
Wall Sconce
Bell Jar Lantern
Candelabra
Ceiling Fixture
Lantern
Wall Lantern
Vanity Light
Pendant Light
Other
21
If other, what type?
22
How many of these fixtures are in this location?* This field is required.
23
Is there anything directly under the fixture that cannot be moved or will make access difficult such as a table, staircase, etc.?* This field is required.
YesNo
24
If yes, please explain.
25
What are the estimated measurements of this fixture in inches?* This field is required.
Height
Width
26
What is the estimated measurement in feet from the floor to the bottom of the fixture?* This field is required.
27
Approximately when was the fixture last cleaned?* This field is required.If you don't know, enter "don't know".
28
Are any repairs needed for this fixture?* This field is required.If you don't know, please select "No".
YesNo
29
If yes, please explain.
30
Please upload 3 photos of this fixture here. 1 full shot, 1 room shot, and 1 close up
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
31
Fixture 2

(Please answer the following questions about Fixture 2. Click 'Next' to begin.)
32
Is this an interior or exterior fixture?* This field is required.
Interior
Exterior
33
What floor is this fixture located on?* This field is required.Ex. 1st floor, 2nd floor
34
What room is this fixture located in?* This field is required.Ex. dining room, living room, kitchen
35
What type of fixture is this?* This field is required.
Chandelier
Wall Sconce
Bell Jar Lantern
Candelabra
Ceiling Fixture
Lantern
Wall Lantern
Vanity Light
Pendant Light
Other
36
If other, what type?
37
How many of these fixtures are in this location?* This field is required.
38
Is there anything directly under the fixture that cannot be moved or will make access difficult such as a table, staircase, etc.?* This field is required.
YesNo
39
If yes, please explain.
40
What are the estimated measurements of this fixture in inches?* This field is required.
Height
Width
41
What is the estimated measurement in feet from the floor to the bottom of the fixture?* This field is required.
42
Approximately when was the fixture last cleaned?* This field is required.If you don't know, enter "don't know".
43
Are any repairs needed for this fixture?If you don't know, please select "No".
YesNo
44
If yes, please explain.
45
Please upload 3 photos of this fixture here. 1 full shot, 1 room shot, and 1 close up* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
46
Fixture 3

(Please answer the following questions about Fixture 3. Click 'Next' to begin.)
47
Is this an interior or exterior fixture?* This field is required.
Interior
Exterior
48
What floor is this fixture located on?* This field is required.Ex. 1st floor, 2nd floor
49
What room is this fixture located in?* This field is required.Ex. dining room, living room, kitchen
50
What type of fixture is this?* This field is required.
Chandelier
Wall Sconce
Bell Jar Lantern
Candelabra
Ceiling Fixture
Lantern
Wall Lantern
Vanity Light
Pendant Light
Other
51
If other, what type?
52
How many of these fixtures are in this location?* This field is required.
53
Is there anything directly under the fixture that cannot be moved or will make access difficult such as a table, staircase, etc.?* This field is required.
YesNo
54
If yes, please explain.
55
What are the estimated measurements of this fixture in inches?* This field is required.
Height
Width
56
What is the estimated measurement in feet from the floor to the bottom of the fixture?* This field is required.
57
Approximately when was the fixture last cleaned?* This field is required.If you don't know, enter "don't know".
58
Are any repairs needed for this fixture?* This field is required.If you don't know, please select "No".
YesNo
59
If yes, please explain.
60
Please upload 3 photos of this fixture here. 1 full shot, 1 room shot, and 1 close up
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
61
Fixture 4

(Please answer the following questions about Fixture 4. Click 'Next' to begin.)
62
Is this an interior or exterior fixture?* This field is required.
Interior
Exterior
63
What is the location of this fixture?* This field is required.Please tell us the floor and room, such as 1st floor dining room, 2nd floor master bedroom, or 1st floor guest bedroom.
64
What type of fixture is this?* This field is required.
Chandelier
Wall Sconce
Bell Jar Lantern
Candelabra
Ceiling Fixture
Lantern
Wall Lantern
Vanity Light
Pendant Light
Other
65
If other, what type?
66
How many of these fixtures are in this location?* This field is required.
67
Is there anything directly under the fixture that cannot be moved or will make access difficult such as a table, staircase, etc.?* This field is required.
YesNo
68
If yes, please explain.
69
What are the estimated measurements of this fixture in inches?* This field is required.
Height
Width
70
What is the estimated measurement in feet from the floor to the bottom of the fixture?* This field is required.
71
Approximately when was the fixture last cleaned?* This field is required.If you don't know, enter "don't know".
72
Are any repairs needed for this fixture?* This field is required.If you don't know, please select "No".
YesNo
73
If yes, please explain.
74
Please upload 3 photos of this fixture here. 1 full shot, 1 room shot, and 1 close up
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
75
Fixture 5

(Please answer the following questions about Fixture 5. Click 'Next' to begin.)
76
Is this an interior or exterior fixture?* This field is required.
Interior
Exterior
77
What is the location of this fixture?* This field is required.Please tell us the floor and room, such as 1st floor dining room, 2nd floor master bedroom, or 1st floor guest bedroom.
78
What type of fixture is this?* This field is required.
Chandelier
Wall Sconce
Bell Jar Lantern
Candelabra
Ceiling Fixture
Lantern
Wall Lantern
Vanity Light
Pendant Light
Other
79
If other, what type?
80
How many of these fixtures are in this location?* This field is required.
81
Is there anything directly under the fixture that cannot be moved or will make access difficult such as a table, staircase, etc.?* This field is required.
YesNo
82
If yes, please explain.
83
What are the estimated measurements of this fixture in inches?* This field is required.
Height
Width
84
What is the estimated measurement in feet from the floor to the bottom of the fixture?* This field is required.
85
Approximately when was the fixture last cleaned?* This field is required.If you don't know, enter "don't know".
86
Are any repairs needed for this fixture?* This field is required.If you don't know, please select "No".
YesNo
87
If yes, please explain.
88
Please upload 3 photos of this fixture here. 1 full shot, 1 room shot, and 1 close up
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
89
Fixture 6

(Please answer the following questions about Fixture 6. Click 'Next' to begin.)
90
Is this an interior or exterior fixture?* This field is required.
Interior
Exterior
91
What is the location of this fixture?* This field is required.Please tell us the floor and room, such as 1st floor dining room, 2nd floor master bedroom, or 1st floor guest bedroom.
92
What type of fixture is this?* This field is required.
Chandelier
Wall Sconce
Bell Jar Lantern
Candelabra
Ceiling Fixture
Lantern
Wall Lantern
Vanity Light
Pendant Light
Other
93
If other, what type?
94
How many of these fixtures are in this location?* This field is required.
95
Is there anything directly under the fixture that cannot be moved or will make access difficult such as a table, staircase, etc.?* This field is required.
YesNo
96
If yes, please explain.
97
What are the estimated measurements of this fixture in inches?* This field is required.
Height
Width
98
What is the estimated measurement in feet from the floor to the bottom of the fixture?* This field is required.
99
Approximately when was the fixture last cleaned?* This field is required.If you don't know, enter "don't know".
100
Are any repairs needed for this fixture?* This field is required.If you don't know, please select "No".
YesNo
101
If yes, please explain.
102
Please upload 3 photos of this fixture here. 1 full shot, 1 room shot, and 1 close up
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
103
Please let us know of any questions or additional comments you may have. CLICK 'SUBMIT' TO COMPLETE YOUR FORM.
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