Address of location for service  *

City  *

Name of Correspondent  *

Title  *

Contact Number  *

Cell Phone

Professional Services (select all that apply) Account reconciliation  Employee development coaching  Logistics assessment  Patient satisfaction  Policies and Procedure development  Service excellence programs  Clerical support  Employee satisfaction programs  Management coaching  Performance Improvement programs  Productivity assessment 

What type of industry will you be needing services for? (specify any details)

Healthcare Facility Services (select all that apply) Environmental Services and management  JCAHO E.O.C. compliance assistance  Plant operations and management  Support Services  Ground services  Per-Diem staffing  Resilient and marble floor-care services 

Please specify the type of organization that will be needing our services

Do you need five or seven day service :  Yes   No 

Do you need day services :  Yes   No 

Do you need evening services :  Yes   No 

How many square feet is your facility :

How many Beds :

What improvements are important to you :

Do you have a targeted budget :  Yes   No 

Are you currently outsourcing the area of need :  Yes   No 

Name of company :

What are the problems you are experiencing :

Would you like a performance improvement program :  Yes   No 

Specify any details :

Building and Hospitality Services (select all that apply) Building maintenance  Ground services  Janitorial services  Support Services  Casual staff  Housekeeping services and management  Resilient and marble floor-care services 

Are you an A, B or Class C building :  Class A   Class B   Class C 

Are you an educational institution :  Yes   No 

Other. Please specify :

Do you need five or seven day service :  Yes   No 

Do you need day services :  Yes   No 

Do you need evening services :  Yes   No 

Do you need night services :  Yes   No 

Do you need floor care services only :  Yes   No 

How many square feet is your building :

What improvements are important to you :

Do you have a targeted budget :  Yes   No 

Are you currently outsourcing the area of need :  Yes   No 

Name of company :

What are the problems you are experiencing :

Would you like a performance improvement program :  Yes   No 

Specify any details :