Intake Form

Welcome to our Authorized Partner Resource page.

If you are an independent contractor with a valid business license and you have a basic business liability insurance policy please take a moment to complete our “Partner Intake Form” to become an Authorized Partner Resource with GA LVT INC.

Once you have completed our intake form Vendor Relations Team Member will contact you to take the next step.

You can also send eMail inquiries to: vendors@galvt.us

THANK YOU FOR YOUR INTEREST!

PERSONAL INFORMATION

Your Full Legal Name (required)

Address (required)
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Mailing Address (if different from physical address)
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Cell Phone (required)

eMail Address (required)

Social Security Number or EIN Number(required)

Date of Birth

Marital Status

Spouse's Name

Spouse Employer

Spouse's Work Phone

COMPANY INFORMATION

Company Name

Physical Address
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Business Mailing Address (if different than above)
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Office Phone

Phone Extension

Hourly Billing Rate (required)

Years in Business

Do you and/or your technicians use Smart Phones (required)

Trade Tools / Materials (required)

Lineman Test Set (Butt-set)Punch Tool (66 blade, 110 blade)Cable TesterFish TapeSheetrock SawToner and ProbeAssorted Modular Inserts (jacks)Assorted Wall PlatesLow Voltage Wall Caddy (MP1P, etc.)Box of PLENUM Cat.5e UTP CableBox of PLENUM Cat.6 UTP Cable

Other Tools

Other Materials

EMERGENCY CONTACT INFORMATION

Full Legal Name

Address

Primary Phone

Phone Extension

Alternate Phone

Relationship


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