Company Information

Company Name
Primary Contact First Name
Primary Contact Last Name
Title
Country
Primary Address
City
State
Zip
Telephone
Email Address
Website
Number of Locations
Number Of Technicians
Number of Trucks

License Information

License acquired
License type:
Issuing State
License #:
EPA Refrigerant Certification?	Yes No
EPA Certification #:
Are you fully insured?	Yes No
Are you bonded?	Yes No

Program Source

Please provide the name of sales representative who referred you:
How did you hear about the program?

Reference Information

Current refrigeration equipment company?

Additional Questions

Do you stock equipment replacement parts?

Yes No

Technicians Attending Certification Class

First Name	Last Name	Technicians E-mail Address	5 Years of Experience?
			Yes No
			Yes No
			Yes No
			Yes No
			Yes No
			Yes No
			Yes No
			Yes No
			Yes No
			Yes No

IMPORTANT:

After successfully completing certification, how do you what your company to be displayed on the online contractor locator? Please supply the contact information requested below:

Company Name
Company Address
Company Phone Number
Company Email
Company Website

Affirmation

I hereby certify that the information provided in this Heatcraft Certified Contractor Network application is true and complete to the best of my knowledge, and that I have read and agree to the accompanying terms and conditions found here.

Please type your name below as confirmation and signature: