Personal Information

Name:
Home Address:
Home Address 2:
City:
State:   Zip:  
Home Phone:
Cell Phone:
E-mail:
Work Address:
Work Address 2:  
City:
State:   Zip:  
Work Phone:
Preferred Method of Contact:  Cell Phone
 Home Phone
 Work Phone
Email

Birthday: Month:       Day: 

Family Information

Family Members' Names:

Pets:

Other Information

How did you hear about us?  Web site
 Referral
 Advertisement
Mailing
Other

I am most interested in:  Errand service
 Personal shopping
 Event planning
Other:

I/we:  Travel frequently
 Entertain frequently
 Need someone to coordinate various aspects of life

I imagine that I will utilize Accion Group approximately:  Occasionally
 1-4 hours/month
 4-8 hours/month
 8-12 hours/month
 14+ hours/month

I would prefer:
 My credit card be charged
 To pay by cash