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Your Road to Success

IMARK Energy Service Partner Program

Application Form

COMPANY INFORMATION

Company Name:

Company Address (HQ location):

City, State, Zip:

Company Website:

Years in operation:

Number of Employees:

Total:

Sales:

Technicians:

Project Managers:

Other:

Minority Ownership status:

Yes No

KEY CONTACT INFORMATION

Name:

Title:

Phone:

Fax:

Email:

LICENSING INFORMATION

States where your employees have completed an installation:

Select the type of license(s) held (if any) for each state selected
Contractor License Business License Electrical License

COMPANY PROFILE

Primary customer types served You must re-enter the Zero’s as necessary or your data will not be accepted.
Please assign an estimated percentage (%) to each type. Totals should equal 100%

Commercial

Educational Facilities

Governments (state, local, federal)

Hospitals

Industrial

Retail

Other

Total

 
Service Profile
Please check the box(es) for those areas of service your company performs.

High performance T8

T5-High Output

Pulse Start

Energy Savings Controls

Daylight Harvesting

 
Lighting Maintenance
Please check the box(es) for those areas of service your company performs.

Fixture Cleaning

Group Re-Lamping

Outdoor Lighting

Signage

None of the above

 
Turnkey lighting retrofit services
Please check the box(es) for those areas of service your company performs.

Detailed Quality Lighting Audits

Energy Efficient Lighting system design and consultation

Material procurement/management

Monitoring and verification of client energy savings

Project Management

Rebate Management

Recycling of ballasts and lamps to an EPA approved facility

None of the above

If your company performs other related services not
mentioned above, please list here.

 
Your company’s Industry affiliations
Please check all that apply

AEE-Association of Energy Engineers

IESNA-Illuminating Engineering Society of North America

LEED-Leadership in Energy and Environmental Design

NAESCO- National Association of Energy Service Companies

NALMCO- International Association of Lighting Management Companies

PLASMA- Professional Lighting and Sign Management companies of America

USBGC- United States Green Buildings Council

Other

 
Credentials held by one or more employees of your company
Please check all that apply

CEM (Certified Energy Manager from AEE)

CLEM (Certified Lighting Efficiency Professional from AEE)

CLMC (Certified Lighting Management Consultant from NALMCO)

EEC (Energy Efficiency Contractor from NAESCO)

ESCO (Energy Service Company form NAESCO)

ESP (Energy Service Provider from NAESCO)

LC (Lighting Certified from the IESNA)

LEED (Leadership in Energy and Environmental Design from the USGBC)

Other

 

Liability Insurance Carried

Yes

No

Types of coverage
Please check the box(es) for those areas of service your company performs. Whole numbers only, no comma’s please
 

Limits of coverage:

General commercial liability

 

$

Excess/Umbrella liability

 

$

Workmen’s compensation and employer’s liability

 

$

Insurance Carrier:

Phone Number:

Please provide three (3) Business Credit References:
(For internal use only)
Company Name:
Company Address:
City, State, Zip Code:,
Company Phone:
Company Fax:
 
Company Name:
Company Address:
City, State, Zip Code:,
Company Phone:
Company Fax:
 
Company Name:
Company Address:
City, State, Zip Code:,
Company Phone:
Company Fax:

Warranties offered (other than manufacturers)
maximum 4,000 characters
 
Testimonials and Success stories (optional):
maximum 4,000 characters

 

 

 

 

 

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