First Name 
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					Last Name 
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					Address 
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					City 
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					State 
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					District of Columbia Maryland Virginia  
				  
					  
				   
				  
					Postal Code 
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					Phone 
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					Alternate Phone 
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					Best time to call 
					: 
					Morning Afternoon Evening  
				  
					  
				   
				  
					Email Address 
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					Job Description(Please describe  
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					Project Budget 
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					Estimated time to start 
					: 
					1-2 Weeks Within 1 Month 1-3 Months Immediately, my wife is nagging me constantly Immediately, my husband is glued to the couch  
				  
					  
				   
				  
					How did you hear about us 
					? 
					Internet 
						  Postcard Mailer 
						  Magnet Mailer 
						  Newspaper 
						  Realtor 
						  Newsletter 
						  Referral 
						  Yellow Pages 
						  Clipper Magazine 
						  Home Show 
						  Corporate Partner 
						  Other 
						 
				 
				  
					  
				   
				  
					I UNDERSTAND AND ACKNOWLEDGE THAT Home Improvement Remedies  IS A REFERRAL SERVICE AND WILL REFER 
					CONTRACTORS TO ME. ANY ARRANGEMENTS MADE, OR CONTRACTS NEGOTIATED ARE BETWEEN ME AND THE CONTRACTOR. Home Improvement Remedies  HAS NOT MADE ANY 
					WARRANTIES, EXPRESS OR IMPLIED TO ME AND SPECIFICALLY EXCLUDED FROM THIS JOB ORDER FORM ARE IMPLIED WARRANTIES OF MERCHANTABILITY AND THAT 
					Home Improvement Remedies  SHALL NOT BE HELD LIABLE FOR ANY DELAY OR FAILURE OF CONTRACTOR TO RENDER SERVICES DUE TO FEDERAL, 
					STATE OR MUNICIPAL ACTION OR REGULATION; FIRED DAMAGE TO OR DESTRUCTION IN WHOLE OR IN PART OF HOMEOWNERS PREMISES; LACK OF OR INABILITY TO 
					OBTAIN RAW MATERIALS, LABOR, FUEL, OR SUPPLIES; OR ANY OTHER CAUSES, CONTINGENCIES OR CIRCUMSTANCES WHICH PREVENT OR HINDER CONTRACTOR 
					FROM RENDERING SERVICES OR COMPLETING ITS CONTRACT WITH ME. I HEREBY HOLD Home Improvement Remedies  HARMLESS FROM ANY DEFECT IN 
					WORKMANSHIP, DEFAULT, DAMAGE, INJURY OR EXPENSE ARISING OUT OF THE WORK PERFORMED BY A CONTRACTOR REFERRED AND HIRED BY ME FOR ALL JOBS.