| Contact
Information |
| Owner/Contact
* |
|
| Company Name |
|
| Mailing
Address * |
|
| City * |
|
| State * |
|
| Zip * |
|
| County * |
|
| Phone * |
|
| Fax |
|
| Email Address
* |
|
|
|
| Store
Information (If different then Mailing Information) |
| Store Address |
|
| City |
|
| State |
|
| Zip |
|
|
|
| Service
Company Type |
Service Company Servicing Dealer |
| Form of
Ownership |
Sole Proprietor Partnership Corporation |
| Tax ID Number
* |
|
| . |
|
| Emergency
Service Information |
| Emergency
Service?* |
Yes No |
| Emergency
Phone Number |
|
| Emergency Service
Description |
|
| . |
| Products Serviced (Check All That Apply) |
| Air Conditioning |
Kitchen |
| Commercial Laundry |
Laundry |
| Gas Range |
Microwave |
| Hot Water Dispenser |
Refrigerator |
| Ice Maker |
Sealed System |
| Dehumidifier |
|
| *
required |
|
