Fields marked with a * are mandatory. Please take care to fill in all necessary information. Incorrect or missing information will delay your application. If you are unsure please contact us.

Contact Information
Surname:	*
First Name:	*
Home/Mobile:	*
Work:
Email:	*
Address:	*
Postcode:	*
Schedule and Housework Details
Hours Required:	2 hours 3 hours 4 hours 5 hours Other Please select Hours are per week. If other hours are required please specify how many in the box below. We advise 1 hour per bedroom for the size of the house *
If other please enter:
Days Preferred:	Please note that days are subject to availability. *
Housework required:	*
Payment Details
Management Fee:	Payable quarterly in advance by standing order and is automatically calculated according to how many hours per week the cleaner is required. We will contact you shortly regarding the payment fee. Fees are as follows... 2 hours - £65.00 3 hours - £97.50 4 hours - £130.00 If more than 5 hours per week are required a management fee will need to be discussed and agreed with Aid to Freedom.
First fee payment :	Please select Cheque Debit Card Credit Card Credit and Debit Card payments can be made by telephone. Cheques are made payable to:-     Aid to Freedom     3 Marshall Crescent,     Morley,     Leeds,     LS27 0HB *
Other Details
Do you smoke:	Please select Yes No *
Give cleaner Alarm?	Please select Yes No *
Give cleaner the Key?	Please select Yes No *
Further comments:
Confirmation and declaration
	By entering this security number we can establish if you are a human, and not an internet robot that may send us harmful emails. *
By submitting this form I confirm that I have read, understood and agree to the terms and conditions of the agreement and declare the information I have submitted to be correct.