Ethical Floor Care: Ethical Floor Care: For My Clients

Client Profile Survey

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Last Name *

First Name *

Birthday (month)

Birthday (day)

Street Address *

City *

State *

Zip Code *

Home Phone

Mobile Phone

Work Phone

Profession (ex. Doctor, Lawyer, Teacher, Mechanic)

Email *

Homeowner?

Yes No

Age of Home

Subdivision's Name

Is there an HOA?

Yes No

Do you receive an HOA Newsletter

Yes No

Are you a member of Angie's List?

Yes No

How Often would you like to have your carpets cleaned?

Does any one smoke in the home?

Yes No

Have Air Ducts ever been cleaned?

Yes No

If NO, do you have interest in having them cleaned?

Yes No

If YES, how long ago?

Does anyone have Allergy problmes?

Yes No

Do you have Pets?

Yes No

Dog

Cat

Please check ALL that appply to your home's Flooring

Carpet

Tile

Wood

Marble

Brick

Concrete

Oriental Rugs

Other

Please check ALL that appply to your home's Upholstery

Cotton

Synthetic

Microfiber

Leather

Not sure

We would like to help support your local community and interest groups and/or organizations.

Do you attend church?

Yes No

If so, what is your church's name?

Do your kids attend local schools K-12?

Yes No

If so, which school district?

If we could share a program with you that would benefit your local schools, church or organization would you be interested?

Yes No

( * Required Field )