Liability Application For Pest Control Program Page 2
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425.
Indicate the percentage of the type of clients you serve (must equal 100%):
_______ % Commercial/Industrial
_______ % Residential (Private Homes)
_______ % Food Processors
_______ % Attached Housing (Apartments, Condominiums, Townhomes, etc.)
_______ % Municipalities
_______ % Hospitals/Healthcare Facilities (must complete 25A)
_______ % Restaurants
_______ % Schools/Daycare Centers (must complete 25B)
_______ % Other (Describe): _____________________________________________________________________
25A. HOSPITALS/HEALTHCARE FACILITIES SUPPLEMENTAL QUESTIONS:
1. Are treatments provided inside facility?
Yes
No
If Yes
, please provide a brief narrative of
chemicals used and areas serviced.
_________________________________________________________________________________________
_________________________________________________________________________________________
25B. SCHOOL/DAYCARE SUPPLEMENTAL QUESTIONS:
1. List the names of school/daycare clients:
_________________________________________________________________________________________
2. Do you currently treat inside these facilities?
Yes
No
3. Have you ever in the past treated inside these facilities?
Yes
No
4. What chemical/products are utilized?
_________________________________________________________________________________________
5. List the areas of treatment, inside facility:
_________________________________________________________________________________________
6. List the precautions and/or restrictions that are taken when treating for these type of clients:
7. How long have you been treating these type facilities? __________________________________________
26.
Sales And Chemical Information
Estimated Gross
Estimated Gross
Chemicals/Products or
Receipts
Payroll
Baiting Systems Utilized
(Must be Completed)
$ _________
$___________ ___________________
A. Service as WDO/WDI Inspector only
B. Extermination:
• Bedbugs (complete #26A if providing
Bedbug Treatments)
$ __________
$ ___________
____________________
• Insects
$ __________
$ ___________
____________________
• Rodents
$ __________
$ ___________
____________________
• Termites
$ __________
$ ___________
____________________
• Mosquitoes
$ __________
$ ___________
____________________
C. Landscape Gardening (laying out grounds,
planting trees, shrubs, flowers, etc.)
$ __________
$ ___________
____________________
D. Tree/Shrub or Lawn Spraying, Dusting (license
required to apply chemicals used)
$ __________
$ ___________
____________________
E. Lawn Care (mowing, edging, fertilizing, using
over the counter chemicals)
$ __________
$ ___________
____________________
F. Fumigation
$ __________
$ ___________
____________________
G. Other Operations (Specify):
$ __________
$ ___________
____________________
__________________________________________
Cost
(actual amount paid to subcontractor):
H. Subcontracted Work
$ __________
$ ____________________________
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