Servicer Sign-Up / Update Form

Items with an asterisk (*) are required. please provide accurate information to process your request

general

Are you tax exempt?*

Servicer Info

Name *

Phone*

Email*

Address*

City*

State*

Zip/Postal Code*

Type of business*

Resale #*

Federal Tax ID #*

Dunn & Bradstreet Number*

Officer name & title

Attach W-9 Form*

Click to upload or drag and drop PNG or JPG (max. 10MB)

Liability Insurance Info

Insurance company*

Agent name*

Address*

City*

State*

Zip/Postal Code*

Policy #*

Coverage limits*

Attach Proof of Insurance*

Click to upload or drag and drop PNG or JPG (max. 10MB)

Banking

Terms requested*

Areas of Coverage

Zip codes covered* (separated by comma)

Training & Expertise

Number of technicians*

Certifications*

Refrigerator brands you have serviced*

Ice machine brands you have serviced*

What type of vacuum pump do you use?*

What type of volt meter do you use?*

Hours of operation (M-F)*

Hours of operation (Sat)*

Are you open on Sundays or Holidays?*

Do you service R600a refrigerant?*

Do you facilitate product exchanges?*

Rates

Requested service call flat rate*

Out of area mileage rate*

Sealed system repair flat rate*

In consideration for an account, said business promises to pay for all purchases. In the event any third parties are employed to collect any outstanding or disputed monies owed by said business the undersigned agrees to pay reasonable collection costs, including attorney fees, whether or not litigation has commenced, and all costs of litigation incurred. The undersigned represents that he/she has the authority to execute this credit agreement on behalf of the business identified.

Servicer Sign-Up / Update Form

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