Imark Group – Member Owned, Member Governed

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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