Contractor Application

PUSH Ministry HOME Rehabilitation Program

Contractor Application for Firms and Individuals
Name

First Name Last Name
Email
example@example.com
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please select all that apply:

Minority-Owned Business Woman-Owned Business Small Business Veteran-Owned Business
Do you have Property Damage/Liability Insurance?

Yes No
Length of years in business:
Are you licensed by the State of Georgia Construction Industry Licensing Board?

Yes No
Please list all other licenses and certifications:
Areas of Expertise/Experience:

Grading Concrete Framing Roofing Plumbing Electricity Energy-Certified HVAC Flooring Siding Insulation Drywall/Sheetrock Interior Trim Other
Lead Based Paint Certification

Yes No
Credit Standing

Good Fair Needs Improvement
Jobs Completed:
Jobs in Progress:
Should be Empty:

PUSH Ministry HOME Rehabilitation Program