Contractor Request Form – Potomac Edison

Step 1 of 4

Step 1

Primary Contact Information

The person completing this application should be the primary contact.

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Record Type

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Application Type

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Referrer

First Name(Required)

Last Name(Required)

Title(Required)

Email(Required)

Work Phone(Required)

Mobile Phone(Required)

By providing a mobile number, I authorize to contact me at the phone number I provided via text, an automated telephone dialing system, or artificial or prerecorded voice messages, for any purpose. This is not required to apply. I can opt-out by contacting GreenSky® at 1-866-936-0602 or P.O. Box 24929, Atlanta, GA 30359.

Company Name(Required)

Business Structure(Required)

Number of Employees(Required)

Do you have a website?(Required)

Website / Business URL(Required)

Website / Business URL - NA(Required)

Step 2

Business and Owner Information

Business Information

Type of Service / Product Business Offers(Required)

Doing Business As(Required)

Federal Tax ID(Required)

Contractor License #(Required)

In Business Since(Required)

Annual Consumer Sales Revenue(Required)

Annual Consumer Finance Volume(Required)

Average Ticket(Required)

Street Address(Required)

City(Required)

State(Required)

Zip(Required)

Country(Required)

Different Mailing Address

Mailing address is different form above

Mailing Street Address(Required)

Mailing City(Required)

Mailing State(Required)

Mailing Zip(Required)

Mailing Country(Required)

Principal, Partner or Owner Information

(Please provide all owners who have at least 10% ownership or greater below.)

Owner 1 First Name(Required)

Owner 1 Last Name(Required)

Owner 1 Email(Required)

Owner 1 Mobile Phone(Required)

Owner 1 Title(Required)

Owner 1 Birthdate(Required)

Owner 1 Social Security Number(Required)

Social Security Number will be used to verify company ownership

Owner 1 % Ownership(Required)

Please enter a value between 1 and 100

Owner 1 Owner Since(Required)

Owner 1 Street Address(Required)

Owner 1 City(Required)

Owner 1 State(Required)

Owner 1 Zip(Required)

Owner 1 Country(Required)

Add Additional Owner

Owner 2 First Name(Required)

Owner 2 Last Name(Required)

Owner 2 Email(Required)

Owner 2 Phone(Required)

Owner 2 Title(Required)

Owner 2 Birthdate(Required)

Owner 2 Social Security Number(Required)

Social Security Number will be used to verify company ownership

Owner 2 % Ownership(Required)

Please enter a value between 1 and 100

Owner 2 Owner Since(Required)

Owner 2 Street Address(Required)

Owner 2 City(Required)

Owner 2 State(Required)

Owner 2 Zip(Required)

Owner 2 Country(Required)

Add Additional Owner

Owner 3 First Name(Required)

Owner 3 Last Name(Required)

Owner 3 Email(Required)

Owner 3 Phone(Required)

Title(Required)

Birthdate(Required)

Social Security Number(Required)

Social Security Number will be used to verify company ownership

% Ownership(Required)

Please enter a value between 1 and 100

Owner Since(Required)

Street Address(Required)

City(Required)

State(Required)

Zip(Required)

Country(Required)