Service Application Form

Company Legal Name*

Trade Name

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Shipping Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Main Phone*

Other Phone

Email*

Fax

When was the business started?

How long at present location?

Owner/Manager Name*

Owner/Manager Email*

Accounts Payable Contact Name

Accounts Payable Contact Email

Service Contact Name*

Service Contact Email*

Service Contact Phone*

Service Information

Products Serviced

Products Installed

Other Brand Names Serviced

Primary Areas/Cities/Counties/Zip Codes Covered

Area of Coverage*

Number of Service Technicians

Number of Qualified Electricians

Number of Gas Technicians

Rate structure*

Rate*

Trip Fee

Mileage fee and distance