S.Q.C.C.P. Application

Contact Information

Name

Street Address

City ST ZIP Code

Home Phone

Work Phone

E-Mail Address

Availability

During which hours are you available for a telephone interview?

Weekday mornings

Weekend mornings

Weekday afternoons

Weekend afternoons

Weekday evenings

Weekend evenings

Interests

Tell us in which areas of cleaning assistance do you need. Type “Y” for yes “N” for no

Kitchen

Bedrooms

Bathrooms

Living area

Other-Describe

What are your Needs?

Summarize why it is that you need assistance cleaning. How often would you need help?