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Google
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Referral: If a referred, please state the referral name so we can thank them.
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If you were referred to us can you please let us know who that person was, so we can thank them.
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Customer Key Contact Name
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First Name
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Key Contacts Direct Line
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Customer Type
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Business Name, if applicable
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Business Phone Number, if applicable
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Site Address
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Street Address
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Other
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
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Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
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Macedonia
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Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
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Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
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Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
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British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
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Billing Address (if different from site)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
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11
Job Site Coordination Contact Name, if applicable
First Name
Last Name
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12
Job Site Coordination Contact Mobile Phone Number, if applicable
Please enter a valid phone number.
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13
Job Site Coordination Contact Email, if applicable
example@example.com
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14
Accounts Billable Contact Name, if applicable
First Name
Last Name
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15
Accounts Billable Contact Email, if applicable
example@example.com
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16
Customer Category
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This field is required.
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Property Manager
Strata Corporation
Commercial Contractor
Residential Contractor
Interior Designer
Business Owner
Industrial Business Owner
Residential Home Owner
Healthcare Business
Agricultural/Farm
Telecom Utilities
Institution (provincial & municipal government, education, health authority)
Please Select
Please Select
Property Manager
Strata Corporation
Commercial Contractor
Residential Contractor
Interior Designer
Business Owner
Industrial Business Owner
Residential Home Owner
Healthcare Business
Agricultural/Farm
Telecom Utilities
Institution (provincial & municipal government, education, health authority)
This helps us to assign you to the right team, to ensure optimal work flow.
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17
Project Type
*
This field is required.
Please Select
Strata & Property Services
Electric Vehicle Infrastructure
Maintenance Contract/Operating Permits
General Service Call (Under $4000)
Commercial Tenant Improvement
New Build Commercial
Residential Renovation
New Build Residential
Industrial
Please Select
Please Select
Strata & Property Services
Electric Vehicle Infrastructure
Maintenance Contract/Operating Permits
General Service Call (Under $4000)
Commercial Tenant Improvement
New Build Commercial
Residential Renovation
New Build Residential
Industrial
Help us clarify who within our organization to direct your request to.
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18
Building construction type
*
This field is required.
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Wood frame
Concrete
Concrete & Wood frame mix
Highrise
Outdoor
Other
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Please Select
Wood frame
Concrete
Concrete & Wood frame mix
Highrise
Outdoor
Other
Please let us know your construction type
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19
Building type
*
This field is required.
Please Select
Single Family Dwelling
Multifamily Dwelling
MDU (Mixed Dwelling, Commercial/Residential)
Commercial/Retail Space
Industrial
Agricultural/Farm
Hazardous Location
Please Select
Please Select
Single Family Dwelling
Multifamily Dwelling
MDU (Mixed Dwelling, Commercial/Residential)
Commercial/Retail Space
Industrial
Agricultural/Farm
Hazardous Location
Please let us know the purpose of your building
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20
Scope of Work
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This field is required.
Please let us know what rough idea of the scope of work?
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21
What Is Your Budget For Your First Work Request?
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This field is required.
If you have no idea, please list a general number so we can try to work within your budget.
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22
Electrical Service Required
*
This field is required.
Please choose one or more, or none
Electrical, General
Lighting
Lighting Controls
Emergency Standby Power
Fire Alarm
Industrial Motors & Motor Controls
Off Grid/Remote Microgrid Solutions
Renewable Power Systems (Solar, Wind, Hydrogen)
Electrical Design
Electrical Planning Report (EPR, Strata's)
Electric Vehicle Supple Equipment (EVSE)
Electrical Operating Permit (EOP, Stratas, Commercial, Industrial, any building with a fire alarm)
None
Other
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Communications Services Required
*
This field is required.
Please choose one or more, or none
Data Communications (structured cabling)
Audio/Video
Smart Home Controls
Fiber Optics
WiFi Infrastructure
Cellular Infrastructure
Communication Design
Security Cameras
Security Systems
None
Other
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Photos, Plans, Project & Equipment Specifications, If Available
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
If files are to large, please attach a FTP folder or cloud file storage link in scope of work above.
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25
Estimate Due Date
*
This field is required.
-
Please Note: Due to the procurement system of our wholesalers, estimates under $10K may take up to 7 business days, $10K and over may take 8 business days, estimates $50K and over may take 10 - 30 business days depending on the scale.
Month
Day
Year
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26
Estimate Due Time
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Minutes
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PM
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27
Estimated Work Start Date
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If ASAP leave blank and note it in scope of work. If it is an unsafe electrical hazard, please call 778-822-7654
Month
Day
Year
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28
Estimated Work End Date
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If unknown leave blank
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