Fleet Vendor Application

1
Welcome! Let's get you set up as an Road Rescue Network vendor. What's your company name?* This field is required.
2
Do you have a DBA (Doing Business As) name?
3
What's your Federal Tax ID (EIN)?* This field is required.You may use your Social Security Number if you are a Sole Proprietor
4
How many years has your company been in business?
5
What's your company website? (optional)
6
What's your business address?* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
What's your main company phone number?* This field is required.
Please enter a valid phone number.
8
Who should we contact for service/dispatch? (Full Name)
First Name
Last Name
9
What's the service contact's phone number?
Please enter a valid phone number.
10
What's the service contact's email?
[email protected]
11
Who handles your accounting/invoicing? (Full Name)
First Name
Last Name
12
Accounting contact phone?
Please enter a valid phone number.
13
Accounting contact email?
[email protected]
14
What type of business are you? (Select all that apply)
Small Business
Minority-Owned
Woman-Owned
Veteran-Owned
None of these
15
How many service bays do you have?
16
How many mobile service units/trucks?
17
Do you offer 24/7 emergency service?
Yes
No
18
Which TRUCK REPAIR services do you offer? (Select all that apply)
Diesel Engine Repair
Gas Engine Repair
Transmission Repair
A/C Service HVAC
APU
Exhaust DPF After-Treatment
Electrical Systems
Brake Repair
Suspension Steering
Fuel System Repair
Mobile Diagnostics
Forced Regens
DOT Inspections
PM Preventative Maintenance
19
Which TRAILER REPAIR services do you offer? (Select all that apply)
Brake Repair Air Electric
Landing Gear Repair
Liftgate Repair
Mobile Welding
Tanker Repair
Lighting Electrical
Fifth Wheel Kingpin
Roll-Up Door Repair
20
Which MOBILE TIRE services do you offer? (Select all that apply)
Tire Repair Plug Patch
Tire Replacement
Tire Mounting Dismounting
Wheel Seal Repair
Hub Bearing Service
Roadside Tire Service
21
Do you offer TOWING & RECOVERY? (Select all that apply)
Light Duty Towing
Medium Duty Towing
Heavy Duty Towing
Rotator Service
Winch Out Recovery
Load Swap
Accident Recovery
22
Any SPECIALTY SERVICES? (Select all that apply)
Refrigeration Reefer Repair
Locksmith Lockout Service
Key Cutting Programming
Heavy Equipment Repair
Crane Inspections
Forklift Service
Bus Repair
RV Repair
23
What's your daytime labor rate per hour?
24
After hours rate per hour?
25
Weekend rate per hour?
26
Emergency/holiday rate per hour?
27
Service call fee?
28
What's your Auto Liability policy number?
29
Auto Liability expiration date?
Date
Month
Day
Year
30
General Liability policy number?
31
General Liability expiration date?
Date
Month
Day
Year
32
Workers Comp policy number?
33
Workers Comp expiration date?
Date
Month
Day
Year
34
Upload your Certificate of Insurance* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
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35
Upload your W-9 form* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
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36
Almost done! Please confirm the information is accurate and sign below.* This field is required.
37
Signature (draw your signature below)* This field is required.
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