Heavy Duty Mobile Technician Registration

1
First & Last Name
First Name
Last Name
2
Company Name (Leave blank if individual)
3
Email Address* This field is required.
example@example.com
4
Phone Number* This field is required.
Please enter a valid phone number.
5
Do you consent to receive calls or texts regarding your services?* This field is required.
Yes
No
6
Phone Type
iPhone
Android
Other
7
Date of Birth* This field is required.
Date
Month
Day
Year
8
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
Country
9
Services Offered: Truck Repair
APU (Auxiliary Power Unit)
Air Conditioning (Cab AC)
Axles
Belts & Hoses
Brakes
Clutch
Compressed Air Systems (Air Dryers, Air Tanks, Valves)
Cooling System (Radiator, Water Pump, Thermostat)
Diagnostics
Differential
DOT Inspections
Drive Line / Drivetrain
Electrical
Emissions System (EGR, SCR)
Exhaust (Manifold, Muffler)
Exhaust DPF
Fan & Fan Clutch
Forced Regens
Frame & Chassis
Fuel System
Gas Engine
HVAC
Lighting
PM (Preventive Maintenance)
Power Steering
Sensors & Modules
Suspension
Transmission
Turbocharger
Wheels & Hubs
Other
10
Services Offered: Trailer Repair
ABS (Trailer ABS / ECU)
Air Lines & Glad Hands
Axles
Brakes
Cargo Securement (Rails, Straps, Load Bars)
Doors (Swing Doors)
Fifth Wheel / Kingpin Interface
Flooring
Landing Gear
Liftgate
Lighting
Roof & Panels
Roll-Up Door
Suspension
Tanker (Valves, Pumps, Hoses)
Tires & Wheels
Welding & Fabrication
Other
11
Services Offered: Tire Services
Air Pressure Adjustment
Blowout Replacement
Dual Tire Replacement
Emergency Roadside Tire Service
Lock Ring Inspection (Dayton)
Mount & Dismount
Retorque / Torque Check
Rim / Wheel Inspection
Spare Tire Installation
Tire Inflation (Service Call)
Tire Repair (Plug / Patch – When Permitted)
Valve Stems & Cores
Wheel Stud / Lug Nut Replacement
Other
12
Services Offered: Specialty
Reefer
Locksmith
Heavy Equipment
Crane
Forklift
Bus
RV
Other
13
Maximum Travel Distance (miles)
Please Select
Please Select
25
50
75
100
100+
14
Service Vehicle TypeThere are no requirements as to what kind of vehicle you want to use. As long as you're able to get to each job and properly fix. If you need assistancr
15
Onboard Equipment (select all that apply)
Diagnostic Tools
Welding Equipment
Liftgate
Air Compressor
Generator
Other
16
Certifications (select all that apply)
ASE
OEM Certifications
Other
17
Years of Experience
18
License Number
19
License State
20
License Expiration Date
Date
Month
Day
Year
21
General Liability Policy Number
22
General Liability Coverage Amount (USD)
23
General Liability Expiration Date
Date
Month
Day
Year
24
Auto Liability Policy Number
25
Auto Liability Expiration Date
Date
Month
Day
Year
26
Do you have Garage Keepers Insurance?
Yes
No
27
Workers Compensation Coverage
Yes
Exempt
28
Workers Comp Policy Number
29
Workers Comp Expiration Date
Date
Month
Day
Year
30
Have you ever been convicted of a felony?
Yes
No
31
Have you ever been convicted of a misdemeanor?
Yes
No
32
Bank Name
33
Payment Methods Accepted
Card
Fleet Cards
Cash
Invoice
RoadSync
34
Upload a photo of your driver's license* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
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35
Upload Certificate of Insurance (COI)* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
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36
Upload W-9 Form* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
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37
Upload a photo of your service vehicle* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
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38
Upload a photo of your equipment (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
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39
Business Reference 1: Company Name* This field is required.
40
Business Reference 1: Contact Name* This field is required.
41
Business Reference 1: Phone Number* This field is required.
Please enter a valid phone number.
42
Business Reference 2: Company Name* This field is required.
43
Business Reference 2: Contact Name* This field is required.
44
Business Reference 2: Phone Number* This field is required.
Please enter a valid phone number.
45
Business Reference 3: Company Name* This field is required.
46
Business Reference 3: Contact Name* This field is required.
47
Business Reference 3: Phone Number* This field is required.
Please enter a valid phone number.
48
I have read and agree to the terms and conditions.* This field is required.
49
Signature* This field is required.
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