Contractor Application

Rural Preservation Company of Clinton County- Contractor Application

Complete form below
A.) GENERAL INFORMATION
Company Name:
Phone Number:

Area CodePhone Number
E-mail Address:
Owner(s) Name:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Federal and/or State I.D. #:
please type number here
Registered with Clinton County Clerk-DBA?
Number of Years in Business
Type of business

Sole ProprietorshipPartnershipCorporation
Please provide number of employees:

Seasonal Permanent

Number of Employees

	Seasonal	Permanent
Number of Employees

For certification questions, if you answer "yes" please provide copy of certification.

	Yes	No
Do you charge for estimates?
Is the company EPA Lead Based Paint Certified?
Is the company EPA Lead Based Paint Certified for Abatement?

B.) INSURANCE REQUIREMENTS:

Contractors performing work through this program are required to carry a minimum of $500,000.00 in general liability insurance. Worker's compensation and NY Disability are required if contractor has employees. Please submit a certification of insurance, displaying your coverage from your insurance agent.
C.) CREDIT REFERENCES:

Please submit with this application the names, addresses, and telephone numbers for 2 of your recent clients:
Bank Name and Phone Number:
Supplier Name and Phone Number:
Supplier Name and Phone Number:
Signature

Clear
Print Name and Title
Date

MonthDayYear
Date

Rural Preservation Company of Clinton County- Contractor Application