Installer Form





Company Information

Company Name:

DBA:

Ship to Address:

City: State: Zip Code:

Bill to Address:

City: State: Zip Code:

Website: Date:

Contact:

Phone: Ext:

Cell: Fax:

Email Address:

Number of Years in Service:


Licenses, Certifications & Insurance Information

Licensed Cities:

Do you have any additional licenses [Master Electrician, Electrical Contractor, Other]:  Yes No

Please list:

Do you have any Union Affiliations?:

Exp. date:
Have you had any OSHA violations in the last 5 years?:  Yes No

If yes, please explain:


Please supply us with the following:

  1. 1. Certificate of Insurance
  2. 2. W-9
  3. 3. Workers comp

You must provide a certificate of insurance that shows Advance Sign Group, LLC as the certificate holder.


Capabilities

Select all applicable capabilities

Surveys

Permitting

Service

Installation

Certified Electrician

 Yes No

 Yes No

 Yes No

 Yes No

 Yes No

Routing

Vinyl Plotter

Digital Printer

Neon Plant

UL Certification

Engineering Services

 Yes No

 Yes No

 Yes No

 Yes No

 Yes No

 Yes No

Equipment

Mark all that apply

1 man rate [$]

2 man rate [$]

Describe your normal geographic area, in which mileage charges are not assessed:


References


Business Affiliations

Company 1:

Contact:

Address:

Phone:

Company 2:

Contact:

Address:

Phone:


Customers

Company 1:

Contact:

Address:

Phone:

Company 2:

Contact:

Address:

Phone:


Suppliers

Company 1:

Contact:

Address:

Phone:

Company 2:

Contact:

Address:

Phone:


Additional Comments or Qualifications