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 JPS 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, personal check or money order