USSI Global Service Provider Application

Questions? Please contact the Field Service Management Team at [email protected] or (321) 953-5212.

Business Information

Full Legal Name of Company

DBA if any:

Website

Have you done work for USSI Before? yes no

Under Tech Code

Were you referred to USSI? yes no

Who Referred you to USSI

Are you a Nationwide Service Provider yes no

Please upload signed W9

Company Billing Address

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Company Shipping Address

Is the Shipping Address the Same as the Billing Address? yes no

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

For shipping purposes is this a: Residence Business

Are there any details to be aware of when shipping to this location? yes no

Other considerations:

Company Contact Information Insufficient data of lack of an email address may hinder processing of paperwork

Primary Contact:

Title of Primary Contact:

Secondary Contact:

Title of Secondary Contact:

Main Phone Number:

Alternate Phone Nuber:

Cell Phone Number:

Email Address:

Alternate Email Address:

Skype/Facebook/Google Hangouts/Facetime Username (used for video interviews prior to enrollment into USSI network):

Organization of Business Tell use a litte about your business

The structure of your business: Sole Proprietorship Partnership Corporation Limited Liability Company Other

If other please specify:

Date Organized:

Federal Tax ID Number (or SSN):

Principles

Name	Address	Title	Owernship Interest (%)

Number of Employees:

Number of Trucks / Service Vehicles:

Business Hours:

Number of Full Time Technicians:

Number of Subcontractor Technicians:

Technician Information

Tech Name	City	State	Zip Code	Contact Number	Email Address

Territories and Capabilities The locations your service and your service capabilities

The Service Radius in which your perform installation/services (if no radius is listed a default of 75 will be used):

If available, please email an excel file of the ZIP codes you can cover to [email protected]

Are you able to provide Same Day Service?: yes no

Same Day Service Radius (If Applicable):

Are you able to provide Next Day Service?: yes no

Next Day Service Radius (If Applicable):

Are you able to provider 24x7x365 coverage?: yes no

Warehouse Square Footage:

Business Profile

Tell us about your business: (for purposes of developing a profile to internally market your organization to our program groups (at no cost to you). If your profile does not fit here, send information to [email protected])

Business References Please list at least three business references that we may contact if needed.

Business References

Name	Address	Contact Number

Certificate of Insurance

Please send in the Certificate of Insurance(s) meeting the requirements below to USSI via email to [email protected] or via fax to 321-727-3107.

Requirements for Commercial Work: General Liability $1M per Occurrence, General Aggregate $2M Per Project, Auto Liability (Commercial or Personal rated for Business Use) $1M - Approval required for lower limits, Workers Comp - if required by state (if exempt please provide exemption certificate if available)

Experience and Qualifications

How many years in business generally:

How many years in satellite installation business:

Total number of installations completed each month by your company:

Satellite	Digital Signage	TV	Appliance

Total number of Service Calls completed each month by your company:

Satellite	Digital Signage	TV	Appliance

Type of Field Crew Communication

Please describe any relevant work experience (i.e. Commercial VSAT, Digital Media, Military experience. Provide dates, pictures, locations and/or certificates etc. of relevant training)

Languages Spoken (other than English):

State and Local Licenses

Select all applicable State and Local Licenses General Business License Low Voltage License Burglar Alarm License Contractors License Electrical License Fire Alarm License Other

If you selected other, please specify:

Please provide License Numbers:

Please upload a copy of your License

Certifications / Experience Please provide copies of all Certificates for Certifications below if available

Please provide copies of all Certificates for Certifications below if available

Misc. Licenses - Please select all that apply: OSHA Training Completed SeaTel Certification Security Clearance

Satellite Materials - Please select from tools below for pointing Satellite Antennas: Birddog Spectrum Analyzer.DBS Signal Meter Other

If other selected please specifiy:

Structured Wiring - Please select all that apply: Cable Systems Exp Small Office Telephone Exp CAT 5/6 Fiber S-Video Exp Structured Wiring (Pre-Con) ex Residential Telephone Exp

Please advise if there are any Certifications or Experiences that you have that are not listed below

USSI Required Documents and Photos

Please upload the required documents below or send them to Field Services via email at [email protected] or fax at 321-727-3107.

Service Provider Agreement

Service Provider Policy and Procedures Acknowledgement

Background Check Authorization Form - Required for all USSI work

Credit Card Authorization Form - Required for Background Check - $54.11 Per person

Technician Photo

Service Vehicle

Files included with this form:

Signature Required:

For Reference Only:

By entering your name here you hereby agree that all information entered is true and accurate.

USSI Global Service Provider Application Revision Date: 11/8/2017