Installation Partner Form

LET'S GET STARTED!

First Name*

First Name is Required

Last Name*

Last Name is Required

Company*

Company is Required

Email Address*

Email is Required Please Enter a Valid Email

Cell Phone*

Cell Phone is Required

Business Phone*

Company Phone is Required

Company Website*

Company Website is Required

Number of Years in Business*

Year is Business is Required

Geographic Service Area*

Geographic service area is Required

Owner’s Name*

Owner's name is Required

Owner’s Email*

Owner's email is Required Please Enter a Valid Email

Owner’s Phone Number*

Owner's phone number is Required

Owner’s Years of Experience?*

Owner's years of experience is Required

Special Certifications?*

Special certifications is Required

Street Address:

Address:*

Address is Required

City:*

City is Required

State:*

State is Required

Zip:*

Zip is Required

Mailing Address:

Address:*

Address is Required

City:*

City is Required

State:*

State is Required

Zip:*

Zip is Required

Do you have any other Business Ownership Interests:

No

Yes

Please choose an option

If Yes, describe the other businesses:

What type of work does your Company primarily perform (please describe):

Please select the Category that best describes your Company workforce:

How many Full-Time Employees?

How many Part-time or Contract Employees?

Additional Comments: (optional)

Please list all States in which your Company is licensed to do business:

Please check all that apply to your Company status:

Corporation	LLC	Sole Proprietorship
S-Corp	MBE: Minority Business Enterprise	WBE: Women Business Enterprise
VOBEE: Veteran Owned Business Enterprise	SDVOBE: Service Disabled Veteran Owned Business Enterprise	IWDBE: Individuals with Disabilities Owned Business Enterprise

How do you currently manage Safety in your Company? (Please explain):

What types of insurance do you currently carry? (Please check all that apply)

Commercial General Liability Automobile Worker’s Compensation
General Liability Umbrella Policy

Select the yearly revenue category that best fits your current Company.

Why do you feel your Company would be a good partner with Stonhard?

How Did You Hear About Stonhard?

What's The Easiest Way To Reach You?

Email

Phone

Text

Please Select a Contact Method

The information you have provided will help us deliver information to you regarding our products and services. By checking this, you indicate that you have read and agreed to our terms of use and privacy policy. Please read these terms to understand how we protect and manage your data.

Commercial General Liability	Automobile	Worker’s Compensation
General Liability Umbrella Policy