Provider Application Step 1 of 5 20% Legal Business Name(Required) Doing Business As Country(Required)United StatesCanadaBusiness Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Business Address Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Business PhoneDispatch PhoneBusiness Email Dispatch Email Website Tax ID NumberBusiness License/Permit Number Years in BusinessMailing Address (if different than above)(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Mailing Address (if different than above) Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Owner Name First Last Owner PhoneOwner CellManager Name First Last Manager PhoneManager Cell Do you have the ability to accept digital dispatch?YesNoIf No, are you interested in digital dispatch?YesNoDo you perform background checks on all your drivers?YesNoAre your drivers uniformed?YesNoAre you a member of any industry associations?YesNoIf yes, please list the associations of which you are a member.Do you do any Police, Highway Patrol, Sheriff or other towing for law enforcement?YesNoDo you have a secured storage lot?YesNoDo you have an automobile repair facility?YesNoDo you sell tires?YesNoIf yes, check all that apply Auto RV Motorcycle Trailers Do you sell batteries?YesNoIf yes, check all that apply Auto RV Motorcycle Trailers Do you provide Accident Scene towing?YesNoAre you capable of secondary accident towing? (yard to yard, shop to shop)YesNoDo you provide 24 hour towing and roadside assistance?YesNoIf no, please list the days and hours of the week belowWhat are the Zip Codes you cover?Are you willing to travel outside the area or long distances? Yes What methods of payment do you accept from our customers in the event they should have any "non-covered expenses"? Amex Mastercard Visa Discover Personal Check ATM/Debit Towing: (check all that apply) Light Duty Medium Duty Heavy Duty Motorcycle Transport Covered Trailer Towing (antique/luxury) Services: (check all that apply) Jumpstart Lockout Tire Change Tire Inflation Unleaded Fuel Delivery Diesel Fuel Delivery Winching Flat Bed Towing Low Clearance Towing (parking garages) under 8' Motorcycle Jumpstart Heavy Duty Jumpstart Locksmith Battery Install/Sale Onsite Tire Repair/Sale Windshield Repair Paintless Dent Repair Stabling Gooseneck Towing Tandem Towing (truck and trailer) Ball and Hitch Towing Fifth Wheel Towing Mobile Mechanic (diesel) Mobile Mechanice (non diesel) Long Distance Towing Horse Transport Equipment: (check all that apply) Wheel Lifts Flatbeds Light Service Units Landoll/Lowboy Medium Duty Units Heavy Duty Units Super Duty Units Fifth Wheel Motorcycle Carriers (other motorcycle specific equipment) Covered Trailers Upload Documents Drop files here or Select files Max. file size: 50 MB. NameThis field is for validation purposes and should be left unchanged.