First Name
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Last Name
*
Service Address
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State
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City
*
Phone
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Email
*
How long have you been a BA House Cleaning client?
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Less than 12 Months
6-12 Months
More than 12 Months
What temporary circumstance is impacting your ability to afford service?
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Job Loss
Reduction of Income
Medical Expenses
Family Emergency
Unexpected Financial Hardship
Other
If other, please state reason. Otherwise, input N/A
*
Approximately how long do you anticipate needing assistance?
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Less than 1 Month
1-3 Months
More than 3 Months
Are you willing to accept the scheduling flexibility required for this program?
I understand that participation requires:
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Service may occur any weekday between 9:00 AM–6:00 PM.
My appointment may be moved or bumped as operational needs require.
Technician consistency may not be guaranteed.
Kindly check to accept terms and conditions.
Acknowledgement
I acknowledge and agree that:
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The Hardship Program provides a 40% discount from standard maintenance rates.
The program lasts for a maximum of three months.
At the end of the approved period, pricing automatically returns to standard rates unless otherwise approved by management.
Participation is not guaranteed and is subject to management approval.
I certify that the information provided is truthful and that I am experiencing temporary financial hardship.
Kindly check all acknowledgements.
Your Signature
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Clear
Signature
Date Today
*
BA House Cleaning Representative
*
Submit