Supplier Registration

Full Legal Company Name

Business Physical Address:

Mailing Address:

Daytime Phone:

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Mobile Phone:

(###)

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Accounts Payable:

Phone

(###)

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Type of company:

Business laws incorporated in:

Years in business:

Secretary of State Charter #:

FEIN:

Owner Name (First, Middle, Last, Suffix) :

Co-Owner Name:

First Name

Last Name

EQ - List of equipment available for rent with typical crew headcount and rates for EQ only. Please also email a separate inventory list - office@atwgroupllc.com

LBR - List of labor available for rent with positions and rates for LBR only. Please email a seperate inventory list to office@atwgroupllc.com

Safety Contact:

Safety Policy Manual, Work in Progress Report, Sample Certificate of Insurance (COI) - must be emailed to office@atwgroupllc.com to be considered. COI - anticipate limits of $1M+GL, $1M Commercial Auto, $1M Workers Comp, as customary. Specific needs may require different terms and endorsements.

Past Disaster work experience:

Insurance Provider Name & Contact Information:

Do you have authority to take equipment out of state?

Any additional information we should know: