Clean Image Corporation

INQUIRY

Name of Company:
Address of location for service:		City:
Name of Correspondent:		Title:
Please provide a telephone number where we can reach you :		Cell:
I am interested in the following services:
• Professional Services Check all that apply
Account reconciliation		Clerical support
Employee development coaching		Employee satisfaction programs
Logistics assessment		Management coaching
Patient satisfaction		Performance Improvement programs
Policies and Procedure development		Productivity assessment
Service excellence programs
What type of industry will you be needing services for Specify any details :

• Healthcare Facility Services Check all that apply
Environmental Services and management		Ground services
JCAHO E.O.C. compliance assistance		Per-Diem staffing
Plant operations and management		Resilient and marble floor-care services
Support 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 Check all that apply
Building maintenance		Casual staff
Ground services		Housekeeping services and management
Janitorial services		Resilient and marble floor-care services
Support Services
Are you an A,B or Class C building :		Are you a hotel : Yes No
Are you an educational institution :	Yes No
Other. Please specify :
Do you need five or seven day services :	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 :