COVID19 VIRAL CLEANING SERVICES INTAKE FORM

VIRAL CLEANING & COVID19 DISINFECTION SERVICES EVALUATION & INSPECTION

INSPECTION & EVALUATION REQUEST FORM
Date & Time Request Sent *
Has anyone working or living at this property tested POSITIVE for COVID19 infection? *

YES NO UNKNOWN
Contact Information:

Decision Maker Contact for Project
Contact Name *

First Name Last Name
Title
Title of Contact (Example: Owner, CEO, Manager, etc.)
Email Address *
Cell Phone/Text *
Customer Secondary Number *
Property Address for Services:

Submit 1 Request For Each Property Needing Service
Business Name: *
(If property is a Business or Entity)
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Property Needing Service Type *

Commercial Office Retail / Shopping Hospital Medical or Dental Office Industrial Warehouse Restaurant Public School College, University or Dormatory Residential Home Apartment Units or Complex Daycare Center Elderly or Assisted Living Complex General Office Fitness Center Church or Synagogue Detention Center Government Office or Building
Will this property need reoccurring cleaning services for COVID19? *

YES NO UNKNOWN
Approximate Square Footage of Property?
Example: 2,400
When Is Service Needed?

ASAP/EMERGENCY Within 1 Week Within 2 Weeks Within 1 Month
What time of day is services needing to be performed and access to property available? *

Business Hours: 8AM-5PM Afterhours: After 5PM Overnight: After 8PM Weekends: Saturday & Sunday
Additional Information about the property, owners or business:
Typ text in box
BIONIC Emergency Services would like to thank you for submitting this information! Once submitted, the BIONIC Staff Member's will immediately go to work to contact and assist you.

If you need immediate reponse, please call 713-338-2424, and let us know you have submitted information.

Thank you for your continued support!

The BIONIC Emergency Services Team
Should be Empty:

VIRAL CLEANING & COVID19 DISINFECTION SERVICES EVALUATION & INSPECTION

Contact Information:

Property Address for Services: