Fabricator/Installer Registration Form
Personal Information
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Company Info
Company Name
*
Company Email
*
Company Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company Phone Number
*
Please enter a valid phone number.
Company Tax ID
Qualifications
List any relevant certifications or licenses
*
Insurance Information
Provide proof of General Liability Insurance with a minimum coverage of $1,000,000
*
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Provide proof of Workers' Compensation Insurance
*
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Signature
By signing below, I certify that the information provided in this form is true and accurate. I understand that any false information may result in termination of my agreement with Groma Consulting Group, Inc. (Surprise Granite DBA).
Signature of Subcontractor
*
Signed Date
*
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Month
/
Day
Year
Date
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