Company Information
Company Name
Doing Business As
Physical Address
Billing Address
Same as Physical
Physical City
Billing City
Physical State
AK
AL
AR
AZ
CA
CAN-AB
CAN-BC
CAN-MB
CAN-NB
CAN-NL
CAN-NS
CAN-NT
CAN-NU
CAN-ON
CAN-PE
CAN-QC
CAN-SK
CAN-YT
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Billing State
AK
AL
AR
AZ
CA
CAN-AB
CAN-BC
CAN-MB
CAN-NB
CAN-NL
CAN-NS
CAN-NT
CAN-NU
CAN-ON
CAN-PE
CAN-QC
CAN-SK
CAN-YT
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Physical Zip
Billing Zip
Phone
Emergency Phone
Email
Website
Business Overview
Company Owner
Number of Employees
Certified Woman / Minority / Veteran Owned
Number of Licensed Electricians
In Business Since
Number of Service Technicians
Federal Tax Id/SSN
Number of Lifts
Number of Bucket Trucks
Dispatch Factors
Distance Willing to Travel
Work Order Capacity
Expertise - Skills (Check all that Apply)
Lighting Maintenance
Retrofit Specialty
Pole Lighting
Sign Lighting
Projects
Neon
Union
Insurance & License Information
Contractor License Number
Electrical License Expiration Date
States Licensed
AK
AL
AR
AZ
CA
CAN-AB
CAN-BC
CAN-MB
CAN-NB
CAN-NL
CAN-NS
CAN-NT
CAN-NU
CAN-ON
CAN-PE
CAN-QC
CAN-SK
CAN-YT
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
COI – General Liability Expiration Date
COI – Work Comp Expiration Date
COI – Auto Expiration Date
Contact(s)
NOTE: Must enter at least two Business Reference Contacts.
First Name
Last Name
Phone
Email
Contact Type
Service Coordinator
Project Manager
Insurance Coordinator
Accounts Receivable
Field Surveys
Quotes
Business Reference
Service Coordinator
Project Manager
Insurance Coordinator
Accounts Receivable
Field Surveys
Quotes
Business Reference
Service Coordinator
Project Manager
Insurance Coordinator
Accounts Receivable
Field Surveys
Quotes
Business Reference