<h1>Certified Service Provider US</h1>
<h2>Contact Information</h2>


<label> Your Business Name (required)
    [text* your-business-name] </label>

<label> Your Name (required)
    [text* your-name] </label>

<label> Your Email (required)
    [email* your-email] </label>

<label> Your Phone Number (required)
    [tel telephone] </label>

<label> Address
    [text your-address] </label>

<label> City
    [text your-city] </label>

<label> State
    [text your-province] </label>

<h2>Business Information</h2>

<label> Cities You Service:
[text your-preferred-city] 
    </label>


<h2>We are looking for Certified Service Providers that can meet all of the following criteria.</h2>
Business Registration
[radio your-businessreg label_first use_label_element default:1 "Yes" "No"]


General Liability Insurance Certificate
[radio your-insurance label_first use_label_element default:1 "Yes" "No"]


Worker's Compensation Insurance
[radio your-clearance label_first use_label_element default:1 "Yes" "No"]


Business Banking Account
[radio your-banking label_first use_label_element default:1 "Yes" "No"]


<label> Number of years in business?
[text your-yearsinbusiness] 
</label>

<h2>Getting to Know You</h2>
As part of CleanMark's selection process we are interested in finding out more about you and the work environment that you are best suited for. Please take a few minutes to complete the following questionnaire by clicking on the link below. The questionnaire will open in a new web page. Once you have completed the questionnaire and submitted, close the page to return to this form. Then, complete this form and send.

<h2><a href="https://assess.piworldwide.com/oi/clean" target="blank">CLICK HERE TO FILL IN THE QUESTIONNAIRE</a></h2>

Please note: You or your employees may be required to clear a criminal background check.

<h2> Human Verification</h2>
 [recaptcha size:compact] 

[submit "Send"]