Contractor Application Form

Company Info
Name of Company:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:

Area CodePhone Number
Company Email:
Contact:

First NameLast Name
Phone Number:

Area CodePhone Number
Contact Email:
ABORIGINAL AFFILIATION:
IF “YES,” PLEASE INDICATE COMMUNITY:
TYPE OF BUSINESS
Please indicate what services your company provides:

INSURANCE
EQUIPMENT AND LIABILITY
Name of Insurance Company:
Name of Insurance Agent:
Policy Number:
Amount of Insurance:
Expiry Date:
Supporting Documentation:

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VEHICLE
Name of Insurance Company:
Name of Insurance Agent:
Policy Number:
Amount of Insurance:
Expiry Date:
Supporting Documentation:

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WORKERS’ COMPENSATION BOARD COVERAGE
Must have coverage for Alberta and British Columbia.
WCB BC Number:
WCB AB Number:
Experience Rating:

REFERENCES
Name of Company #1:
Contact Name:
Phone Number:

Area CodePhone Number
Cell Number:

Area CodePhone Number
Email:
Name of Company #2:
Contact Name:
Phone Number:

Area CodePhone Number
Cell Number:

Area CodePhone Number
Email:
Name of Company #3:
Contact Name:
Phone Number:

Area CodePhone Number
Cell Number:

Area CodePhone Number
Email:

Supporting Documentation
Please attach appropriate information relating to your company (i.e. Health and Safety policies, corporate profile, equipment lists and rate sheets.)
File #1

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File #2

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File #3

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File #4

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File #5

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Today's Date

MonthDayYearHourMinutesAM/PM Option
I certify that the above statements are true and correct, and that I have not knowingly withheld any information that would unfavorably affect my application.
Should be Empty: