Company Name

Select Business format sole proprietorship partnership LLC Corporation Other

Name under which your company does business (which may differ from above)

Company address

City or town

Region, municipality, district

State/Province

Country

 ZIP or Postal Code 

Business phone

FAX

Your email 

Web site (if applicable)

Your first name

Last name

Your title with company

Year business started 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956

Size of cleaning staff:

Number of People on Staff Under 5 6 - 10 11 - 15 16 - 20 21 - 25 26 - 30 31 - 35 36 - 40 41 - 45 46 - 50 51 - 55 56 - 60 61 - 70 71 - 80 81 - 90 90 - 100 Over 100

Do you carry General Liability Insurance?

Select We are covered with liability insurance We are not covered by liability insurance Not available in this country   

If "yes" to above, please state amount of coverage

Name of insurance underwriter 

Insurance Policy #

Are your employees' covered for workplace accidents? 

  Select Our workers are covered for accidents Our workers are NOT covered for workplace accidents Not available in this country

Do you carry third party employee dishonesty insurance?  

  Select Our workers are bonded Our workers are NOT bonded Not available in this country

Are you willing to show clients proof of insurance if requested? 

Yes No

The background checks you perform on employees include (check all that apply):

Criminal History

Driving History

Employment References

Personal References

Do you have a structured training program for your cleaning staff?

 Yes No

Do you have a formal Safety Program for your workers? 

Yes  No

Who provides the cleaning equipment and materials?

  Select from list my company my clients company and client my workers

Is your company affiliated with any of the following (check all that apply)? 

ARCP ISSA Better Business Bureau Chamber of Commerce Other affiliation or membership (name)

I have read and agree to the terms and conditions of participation:  Yes No

Application submitted by 

This Application submitted on Select Month January February March April May June July August September October November December Select Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

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