Legacy Subcontractor/Vendor Application

Legacy Builders & Design Co. INC. - Vendor Application Form

Thank you for your interest in working with Legacy Builders & Design Co. INC. Please complete the following form to provide us with the information needed to evaluate your company as a vendor. All fields are required unless specified otherwise.
1. Company Name:
2. Business Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3. Primary Contact Name:

First NameLast Name
4. Primary Contact Phone Number:
5. Primary Contact Email Address:
6. Company Website (if applicable):
7. Type of Business:

Sole ProprietorshipPartnershipCorporationOther
8. Years in Business:
Services Provided:
9. Please list the services your company provides (eg., HVAC, Electrical, Plumbing, General Maintenance, etc.):
10. Do you specialize in any specific trades?

YesNo
If yes, please specify:
11. Which geographic areas do you service?
12. Do you provide 24/7 emergency services?

YesNo
Licensing and Insurance:
13. Business License Number:
14. State of License Issuance:
15. Do you carry the required insurance coverage? (W-9 and COI will be required):

YesNo
16. Workers Compensation Insurance Policy Number:
17. General Liability Insurance Policy Number:
18. Insurance Carrier:
References:
Reference 1:
Reference 2:
Reference 3:
Billing Information:
20. Billing Contact Name:

First NameLast Name
21. Billing Address (if different from business address):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
22. Billing Email:
23: Payment Terms (Net 30, etc.):
Additional Information:
24. Have you worked with any other general contractors? If yes please list:
25. Please provide any additional information you believe is relevant to your application:
Certification and Signature:

I hereby certify that the information provided in this application is true and accurate to the best of my knowledge. I understand that providing false or misleading information could result in the termination of any agreement with Legacy Builders & Design Co. INC.
Signature

Clear
Printed Name:
Title:
Date:

MonthDayYear
Date
Should be Empty:

Legacy Builders & Design Co. INC. - Vendor Application Form

Services Provided:

Licensing and Insurance:

References:

Billing Information:

Additional Information: