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First Name *

Last Name *

Email *

Phone No. *

Company Name *

Industry Classification *

Healthcare (hospitals, clinics)Transportation (Airline, Buses, Taxis, etc)Business OfficesSports Facilities (Stadiums, Gyms)Hospitality, Food and BeverageEducation (Universities, Schools, Training Centers)Entertainment (Cinema, Amusement Parks)HomeOther

Address Line 1 *

Address Line 2

City *

State / Province / Region *

State *

Postcode

Specific Area to be treated with MicrobeCare

For example, Customer’s Waiting Area, Hotel Rooms, Offices. You may indicate multiple areas)

Size of Area to be Disinfected (sq. ft)

Please indicate approximate size of the area you indicated in the left field (in square feet)

Remarks

Please use this space to provide additional information to us or to ask questions.

Do you wish to have a zoom or phone discussion?
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Phone No. *

If yes, please kindly provide telephone number to call and desired date and time and we will get in touch with you.

Date

Time

Time Zone And Country
Time Zone And Country(GMT-12:00) International Date Line West(GMT-11:00) Midway Island, Samoa(GMT-10:00) Hawaii(GMT-09:00) Alaska(GMT-08:00) Pacific Time (US & Canada)(GMT-08:00) Tijuana, Baja California(GMT-07:00) Arizona(GMT-07:00) Chihuahua, La Paz, Mazatlan(GMT-07:00) Mountain Time (US & Canada)(GMT-06:00) Central America(GMT-06:00) Central Time (US & Canada)