Business Name:

Street Address: City : Postal Code:

Phone: Fax: E-Mail:

Owner's Name: Business Type: Sole Proprietor Partnership Corporation

Partner(s) Name:

Main Contact Person: Number of Years in Business:

Main Scope of Business Performed:

Associate Memberships? Yes No (If YES who) 

Number of Employees :

Number of Active Customers:

Number of Licensed Electricians:

Percentage of business generated by new installations:

Percentage of business generated by service work:

Geographical area covered or will cover:

Any experience installing Power Factor Correction devices: Yes No (If YES please explain)

Any experience installing TVSS devices: Yes No (If YES please explain)

Any experience with lighting retrofits: Yes No (If YES please explain)

Any experience working for government bodies: Yes No (If YES please explain)

Additional notes: