A-GAS Vendor Qualification
Through SafetyPlusWeb CQ
Contact Person's Full Name (for answers relating to this questionnaire)
Contact Person's Email
example@example.com
Contact Person's Direct Phone Number
Please enter a valid phone number.
Company Information
Company Name
*
Tax ID Number
*
Company's Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company Phone Number
*
Please enter a valid phone number.
Website URL (if applicable)
Parent Company Name (if applicable)
Type of Company
*
Please Select
Co-Operative
Limited
Corporation
Limited Liability Company (LLC)
Limited Liability Limited Partnership (LLLP)
Limited Liability Partnership (LLP)
Non-Profit / Not-for-Profit Organization
Partnership
Proprietary Limited Company (Pty. Ltd)
Unlimited Liability Corporation (ULC)
Sole Owner/Sole Trader
Has your company or the owners of your company operated under a different name in the last 3 years?
Yes
No
Year your company was founded
*
Total number of company employees
Company Primary NAICS Code
*
Company's other NAICS code(s) - separate each with a comma
Has your company received any serious citations, violations, and/or charges from OSHA, DOT, or EPA?
*
Yes
No
Was the citation, violation and/or charge declared to be or suggested that it was willful?
Yes
No
Please upload your Certificate of Insurance here - put the date of the earliest to expire policy below. Review the Sample COI information below for requirement specifics.
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A-Gas Sample COI
Earliest policy expiration date
-
Month
-
Day
Year
Date
Relationship with A-Gas
*SPW Admin Only - Upload Revised COI (Insufficient Item)
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*SPW Admin Only - Upload Insurance Renewal
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Which site(s) will you be working on?
Bowling Green
Punta Gorda
Rhome
Submit
Should be Empty: