Independent Service Provider Form

First Name

Last Name

Facility Name

Address

Apt/Unit

City

Zip Code

Email

Phone Number (digits only)

Cell Phone (digits only)

Website URL

Years in Business

Current services offered (indicate all that apply)

Towing

Roadside Assistance

Repair

Body

Vehicle Types Serviced

Light

Medium

Heavy Duty

For road services, what towns/cities are you interested in serving?

Affiliations (such as other motor clubs, state police, professional associations, automotive companies, etc.

Services You Would Like to Provide (check all that apply)

Roadside Assistance

Towing

Car Battery

Approved Auto Repair

Select Federal Tax Classification *

Individual/Sole Proprietor or Single Member LLC

C Corporation

S Corporation

Partnership

Trust/Estate

Limited Liability Company (LLC)

Other

24/7 Operations

Yes

No