* Company Name:
* Contact Person:
* Email Address:
* Physical Address:
* Billing Address::
* City:
* State:
AK - Alaska
AL - Alabama
AR - Arkansas
AZ - Arizona
CA - California
CO - Colorado
CT - Connecticut
DC - Washington DC
DE - Delaware
FL - Florida
GA - Georgia
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MD - Maryland
ME - Maine
MI - Michigan
MN - Minnesota
MO - Missouri
MS - Mississippi
MT - Montana
NC - North Carolina
ND - North Dakota
NE - Nebraska
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VT - Vermont
WA - Washington
WI - Wisconsin
WV - West Virginia
WY - Wyoming
Not USA
* Zip Code:
* Phone Number:
* Mobile Number:
* Fax Number:
* Please specify your service coverage area:
* Do you add any miscellaneous fees to your invoices?
Yes No
If Yes, please explain:
* Number of Techs:
* Number of Vehicles:
* Hours of Operation:
* Do you sub-contract any of your work?
Yes No
* Do you provide 24-hour emergency service?
Yes No
* Do you have a digital camera available?
Yes No
Tax ID Number:
* Insurance: (Please select all that apply )
USD $1 Million Liability Coverage
Workers Compensation Insurance
Hourly Rate:
Two- Man Rate:
O.T. Rate:
* Do you charge a travel/trip charge?
Yes No
If yes, please specify your trip/travel charges:
Please list any services you provide:
* Do you provide services for any other national/regional companies?
Yes No
I certify that any client information obtained through Concept National, LLC. will be kept confidential and will only be used to better perform the services requested by Concept National, LLC.
I certify that any client information obtained through Concept National, LLC. will be kept confidential and will only be used to better perform the services requested by Concept National, LLC.
I certify that I will not solicit any work, etc. from any Concept National, LLC. clients.
I give Concept National, LLC. full permission to run background checks on my company and employees at any time if desired.
I certify that the rates that I have submitted are the best available through my company.
I certify that I have answered the above questions honestly and accurately at the best of my knowledge.