Company Information

Company Name*

Business Type*
CorporationLLCSole ProprietorOther

Years in Business*

Website (Optional)

Primary Contact Information

Full Name*

Title*

Phone Number*

Email Address*

Business Address

Street Address*

Address Line 2 (Optional)

City*

State* (2-letter code)

ZIP Code*

Country*
United States of AmericaCanada

Billing Address

Service Capabilities

Brands Serviced (Optional - separate with commas)

Maximum Service Radius (miles)*

Number of Technicians*

Certifications (Optional)

Drug Testing Policy* YesNo

Background Checks Conducted* YesNo

Fleet Vehicles Count*

Warranty Experience

Do you provide warranty service?* YesNo

Provide In-Home Service?* YesNo

Have Encompass Account?* YesNo

Training Type (Optional)

Test Equipment Available

OscilloscopeMultimeterIsolation TransformerSoldering Equipment

Required Documents

Business License*

Certificate of Insurance (COI)*

Tax Form (W9/W8)*

Technician Certifications

Authorization

I certify that the information provided is accurate and complete. I understand that submission of this application does not guarantee approval.

Printed Name*

Title*

Date*

I certify that all information provided is accurate and complete