Janitorial Services Applicator Certification Form
Use this form to apply for janitorial services applicator certification by providing your contact details, business profile, training, equipment capability, experience, and references.
Applicant Information
Applicant Full Name
*
First Name
Last Name
Business/Company Name
*
Job Title or Role
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Email
Phone
Either
Business and Service Profile
Business Type
*
Sole Proprietor
LLC
Corporation
Partnership
Other
Years in Janitorial Services
*
Primary Services Offered
*
Floor Care
Restroom Sanitation
Office Cleaning
Window Cleaning
Carpet Cleaning
Disinfection
Post-Construction Cleaning
Other
Service Area / Location
*
Operating Hours / Availability
*
Certification and Training Details
Current Certifications Held
Cleaning Industry Management Standard (CIMS)
OSHA 10-Hour Training
OSHA 30-Hour Training
Bloodborne Pathogens
Hazard Communication (HazCom)
Green Cleaning Certification
CPR/First Aid
Other
Training Completed
Chemical Safety
PPE Use and Selection
Dilution and Mixing Procedures
Surface Disinfection Procedures
Slip, Trip, and Fall Prevention
Equipment Operation and Maintenance
Environmental/Green Cleaning Practices
Other
Certification Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expiry Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Completed Product-Specific Application Training
*
Yes
No
Equipment and Chemical Handling Capability
Equipment Available for Applicator Work
*
Backpack Sprayer
Tank Sprayer
Handheld Sprayer
Surface Cleaner
Vacuum Extraction Unit
Pressure Washer
Other
Types of Chemicals or Products Qualified to Apply
*
Disinfectants
Sanitizers
Degreasers
Floor Strippers
Carpet Cleaning Solutions
Glass Cleaners
Odor Control Products
Pest Control Products
Other
Do You Follow Safety Data Sheets and Labeling Procedures?
*
Yes
No
Protective Equipment Used
*
Gloves
Safety Glasses
Face Shield
Respirator
Apron
Protective Footwear
Hearing Protection
Other
Limitations or Restrictions in Service Capability
Work History and References
Work experience summary
*
Previous employer or client references
*
Prior certification or contract history
Most recent employer or client
Years of janitorial applicator experience
Declaration and Submission
Signature
*
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Application
Submit Application
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