Release of Liability Form

Release of Liability Form
Curio Case/China Cabinet Cleaning
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You may copy this page using the "print" function in your browser. Make two copies. Send a
signed copy to COMPANY NAME and keep one for yourself.
-------------------------------------------------------------------This agreement is between COMPANY NAME,and its Employees (hereinafter referred to as
"COMPANY NAME") and (type your full name in the box below):
(hereinafter referred to as "Customer")
Customer has instructed COMPANY NAME to clean the interior of his/her curio case or china
cabinet. The duty involves picking up or somehow moving various items kept in the case/cabinet
so that the shelves can be cleaned and/or dusted, the interior glass can be cleaned and, perhaps,
the curio items and/or china cabinet articles themselves may need to be cleaned in some fashion.
Customer hereby releases COMPANY NAME from all liability arising out of cleaning the
interior of the curio case/china cabinet or its (their) contents. Customer understands that he/she is
completely responsible for repairing or replacing any damaged item or items on the interior or
stored in the interior of the case/cabinet, even if COMPANY NAME may have caused the need
for repair or replacement.
Signed this day (type in the date):
in the following county (type in the county name):
in the following state (type in the state name):
I have read, completed and signed this form with the understanding that everything written
herein is true and correct and I agree to the above and sign of my own free will.
By: ________________________________________
(Customer's signature above)
-------------------------------------------------------------------Please look over this "fill-in-the-blanks" form and complete as much as you desire. We will
always give you a call to work out the details prior to sending a housecleaner. The information
provided to us on this form will give us the information we need to give you an accurate
response to your request when we call you back. This form is best completed by past customers
or potential customers who are not cleaned on a regular schedule by COMPANY NAME. If you
are a regularly cleaned customer of COMPANY NAME please call us if you want to make a
change in your schedule.
-------------------------------------------------------------------Name:
First name
Last name
Home Phone #:
Work Phone #:
Best time to call:
E-mail Address:
Have you used COMPANY NAME before:
Yes No
Date you would like to be cleaned:
-- mm/dd/yy
Time you would like to be cleaned :
-- hh:mm:ss am/pm
Street address - location to be cleaned:
Street Address (cont.):
City:
Zip Code:
Billing Address:
Billing Address (cont.):
Billing - City:
Billing - State/Province:
Billing - Zip/Postal Code:
Billing - Country:
Choose one of the following options:
This is a home which I own and live in:
This is a home I own and rent/lease to others:
This is an apartment/condo I occupy:
This is a commercial site I occupy:
Other:
I would like to be cleaned:
4 hours 6 hours 8 hours More hours
Weekly Bi-weekly Monthly One Time Other
I want a team of two:
Yes No
How many bathrooms:
How many other rooms:
About how many square feet:
Directions to location to be cleaned if not very easy to find:
P.S. These forms can be used for different things, just remove and add to it so that you are
protected from anybody that is sue happy!