Company Name

Select Business format sole proprietorship partnership LLC Corporation Sub chapter S

Company address

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ZIP 

Business phone

FAX

Your email  Web site (if applicable)

Your first name  Last name   Title  Select Owner Manager President Vice President Assistant Manager

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: People 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? Yes No          Amount of Coverage $100,000 $250,000 $500,000 $1,000,000 $1,500,000 $2,000,000 $2,000,000+

Name of insurance underwriter  Policy #

Do you carry workers' compensation insurance?  Yes No

Do you carry third party employee dishonesty insurance (bonding)?   Yes No

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 HistoryDriving HistoryEmployment ReferencesPersonal 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)? 

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

I state that all the information provided above is truthful and I acknowledge same by my electronic signature (enter your name here)  

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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