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Magento 2 FME Module

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Contractor Registration

Personal Information

First and Last Name*

Zip Code*

Email*

City*

Address*

State

Phone Number*

Business Information

Company Name*

Hours of Operation*

Company Address*

TimeZone*

Website*

24hr Emergency Service Available*

Yes
No

Coverage Area(miles)*

License Information

Contractor Licensed State*

Liability Insurance Policy Expiration Date*

Occupational Licensed City*

EPA Certification Type*

I
II
III
Universal

EPA Certification Type*

Upload Your EPA Certification*

Contractor License Number*

Upload Your Contractor’s License*

Contractor License Number*

Upload Proof of Liability Insurance*

Occupational License Number*

References (1)

Trade/Customer Name*

Phone Number*

Address*

References (2)

Trade/Customer Name*

Phone Number*

Address*

References (3)

Trade/Customer Name*

Phone Number*

Address*

*

Yes, I agree to the Terms and Conditions

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