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Full Name of your Business Entity: *
Assumed Business Name: *
Business Address (physical): *
  * * *
Business Address (mailing): *
  * * *
Phone: *
Fax:
Email: *
Website:
Annual Gross Sales Volume:
Additional Locations Information:
Location 1:
 
 
 
 
Location 2:
 
 
 
 
Location 3:
 
 
 
 
Location 4:
 
 
 
 
Location 5:
 
 
 
 
Name(s) of Corporate Officer(s) or Principle(s):
Corporate Officer/Principle:
Marketing:
Training/Operations:
Office Manager:
City or State license(s) held:
Number of years your organization has been in business:
State where your company is registered:
Company Certifications* (check all that apply)
IICRC   Certified Firm   ASCR member   Other

Company Certifications (check all that apply)
AMRT   ASD   CCT HST   OCT   SRT UFT
WRT   Vortex Drying Dri-Zone CR Hydro-Lab
WLS IAQA

 * ASD and/or Vortex Drying Certifications are required.

Current IMACC™ Member Reference(s) Name:
Is your company a member of the Better Busines Bureau? YES NO
Is your company a franchise? YES NO
If yes, please describe:
EQUIPMENT:  

# of standard vans
# truck mount cubes
# box trucks
# pickup trucks
# of Hydro-X's
# of portable extractors
# of Water Claws  

# of air movers
# of dehumidifiers (standard)
# of dehumidifiers (LGR)
# of portable desiccants
# of trailer dessicants
# of Water Out trailers
# of Hepa Vacs
# of HEPA air scrubbers
# of Injectidry's
Other extraction Equipment:
Insurance Information:
General Liability:


Contractors Pollution Liability:


Worker's Comp:


Automobile:
Volume:
Year % Residential Jobs % Commercial Jobs Largest Single Job Average Job Amount
Employee Information:
Current # of Employees
Do your employees wear uniforms? Yes No
Do your company vehicles have logos? Yes No
Do your employees carry proper identification? Yes No
Percentage of mitigation services rendered by subcontractors:
Local Bank Affiliation:
Bank Name: *
Address: *
  * * *
  *
Contact: *
Names of three (3) primary insurance companies you work with on a regular basis:
Company Name : *
Contact Name: *
Phone Number: *
Company Name :
Contact Name:
Phone Number:
Company Name :
Contact Name:
Phone Number:
Insurance Companies that your company currently participates in Preferred Vendor Programs:
Emergency Service Contact Info:
Pager:
Email:
Fax:
Cell Phone w/text address:
AREA(s) OF SPECIALTY (Check all applicable areas)
General Contractor:
Residential
Commercial
% subbed out:
Cleaning:
Carpet Cleaning
Content Cleaning
General Cleaning
Maid Services
% subbed out:
Water Mitigation
Commercial Mitigation
      (24 Hour Service)
Residential Mitigation
      (24 Hour Service)
% subbed out:
Smoke & Fire Mitigation
Board Up
Ozone
Pack Out
Security
Structure Cleaning
Temporary Fencing
Temporary Utility Service
Dry Cleaning
Dry Cleaning
Electrical & Wiring
Electrical
Flooring
Carpet
Tile Work
Vinyl
Wood
Plumbing
Leak Detection
Plumbing
Roofing
Roofing
% subbed out:
Siding
Aluminum
Hard Board
Hardi-Plank/Lapboard
T-111
Vinyl
Specialty Services
Asbestos Abatement
Earthquake Retrofit
Cabinets
Furniture Refinishing
Catastrophe
Mold Remediation
Window & Door
Door
Windows & Glass
Emergency Service 24/7
Yes
No
Emergency Service # :
Software you currently have and use:
Xactimate
JPP
POI
Simsol
States Served:


Counties Served:


Zip Codes Served:
An application fee of $350 must be received with your application.

By signing this Application for IMACC™ Membership you understand that you are allowing IMACC™ to do all acts necessary to investigate your organizations eligibility for membership including but not necessarily limited to a credit check through any nationally recognized credit reporting agency, security background checks through your local law enforcement agency, financial background information report from your bank institution and personal background check regarding the quality of services you have rendered in the past.

I, *, Corporate Officer/Owner of * swear under the penalty of perjury that the information supplied to IMACC™ in this Request for Application is true and accurate. I further authorize IMACC™ to investigate those areas of information disclosed immediately above and any other area they, in their uncontrolled discretion, feel necessary to approve our application for membership into IMACC™. I further state I am over the age of 18 and am qualified to make the representation contained in this Application.

* Corporation
by: * date
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