Rental Application Form

Business Information
Legal Business Name:   Years in Business:  
Doing Business As:   Years trading under present name:  

Physical Business Address
Address1:  
Address2:  
County:  
City:   State: Zip Code:  
Phone Number:   Cell Number:   Fax:  
Website:  

Ownership Information
Title (e.g., CEO/Owner, etc.):   Percentage Owned:   %
Last Name:  
First Name:   Suffix:  
Address 1:  
Address 2:  
City:   State: Zip Code:  
Title (e.g., CEO/Owner, etc.):   Percentage Owned:   %
Last Name:  
First Name:   Suffix:  
Address 1:  
Address 2:  
City:   State: Zip Code:  
Type of Business (tax status):

Operational Information
Total Number of Employees: Number of staff available to give onsite demonstrations: How many vehicles do you use for operations?
     
Do you have a showroom(s):   Yes No Showroom Location:
What are your daily hours of operation? Do you presently perform bathroom modifications?
    Yes No

Litigation
Do you have any outstanding litigation against your company? Yes No

Coverage Area
Please indicate the areas to which you can provide a 72 hour onsite demonstration in response to a qualified lead.
City:  
County:   State:  

City:  
County:   State:  

City:  
County:   State:  

Insurance Information
Do you carry Auto Liability insurance? Yes No
Do you carry General Liability insurance? Yes No
Do you carry Worker's Compensation insurance? Yes No

Certification
Do you, your staff, the company hold any certifications that relate to the sale of Gamburd, Inc.?
Name of Person:  
Certification:  

Name of Person:  
Certification:  

Name of Person:  
Certification:  

Business and Credit Information
Bank Name:  
Bank Address 1:  
Bank Address 2:  
City:   State: Zip Code:  
Checking: Account Number:  
Savings: Account Number:  
Other:  
Account Number:  

Sumbission Information
Application completed by: E-Signature: *
*By selecting this checkbox I acknowledge that I am an authorized agent of the company listed below with the authority to submit this application on their behalf.
For the company: Date:

Business/Trade References
Company Name:  
Type of Account:  
City:   State:   Zip Code:  
Phone Number:   Fax:  
Email:  

Company Name:  
Type of Account:  
City:   State:   Zip Code:  
Phone Number:   Fax:  
Email:  

Company Name:  
Type of Account:  
City:   State:   Zip Code:  
Phone Number:   Fax:  
Email:  

      

You have completed the Gamburd, Inc. online application form.
Please make sure all fields have been filled appropriately.
We will be in touch with you shortly. Thank you.

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