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SERVICE PROVIDER
If you are interested in becoming an Concept National, LLC. service provider, please complete and submit the form below. Your information will then be received by our department for review. 



Vendor Sign-Up Form

Questions marked by a * are required.

* Company Name:
* Contact Person:
* Email Address:
* Physical Address:
* Billing Address::
* City:
* State:
* 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.







80 Kero Road, Carlstadt, NJ 07072   |   201-438-0080 Fax: 201-438-0092   |   E-Mail: service@conceptnational.com

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