Phone: (561) 691-5406        Fax: (561691-5407
                1 (888) 901-4200   

                  ~Technician Application~

Contractor Information

Company Name*
Contact Person
Phone #*
Cell Phone #
Fax #
Email Address*
Do you provide emergency service?*
If yes, emergency phone #
Do you have Liability Insurance?*
Coverage amount
Do you have Workers Compensation Insurance?*
Do you have Workers Compensation State exempt form?*
Please indicate the services you can provide:  Hot WaterExtraction  RotaryShampoo  Strip,Sealand Finish  Machine Scrub and Buff(all hard surfaces)  WindowCleaning  Janitorial  Additionalnot listed 
Please provide a list of equipment you currently use:*
How many miles can you travel?*
Please list cities you can travel to:
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