USSI Global Service Provider Application
Revision Date: 11/8/2017
Questions? Please contact the Field Service Management Team at
[email protected]
or (321) 953-5212.
Files included with this form:
Signature Required:
06302021 - Credit Card Authorization Form
11082017 - Background Check Authorization Form
Service Provider Agreement June 2021
Service Provider Policy and Procedures Acknowledgement June 2021
W9
For Reference Only:
Code of Business Ethics June 2021
Inventory Management Policies June 2021
safety handbook full version June 2021
Service Provider Procedure June 2021
USSI - Sample COI
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
Cell Phone
Radio
Direct Connect
VOIP
other
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
Audio-Visual - Please select all that apply
Akoo Experience
Commercial AV System Exp
ICIA Cert
MMDS Video Exp
Polycom Experience
Samsung Certifications
Telargo Experience
Tandberg Level 2 Certification
Extron
Custom Home Theater Exp
Small/Large Scall Vid Dist Exp
Infocomm CTS Cert
Multi-room Audio Sys Exp
Projector Experience
Samsung Experience
Tandberg Experience
VESA Cert
Basic Home Theater Exp
DM Video Conference Eqp Exp
Install/Svcing Digital Sign Ex
NRTC Cert
Scala InfoChannel 5 Certified
Small Comm Office Exp
Tandberg Level 1 Certification
AMX Certification
Computer / Network Repair - Please select all that apply
Cable Broadband Exp
CEDIA installer level 2 Cert
Cisco Certified Network Eng
Commercial Headend Exp
Crestron Level 2 Cert
LAN Networking Exp
Wireless Experience
PC Repair Exp
CEA Consumer Electronics Assoc.
CEDIA Experience
Certified Wireless Network Adm
CISCO Experience
Crestron Exp
CrossMatch LSMS Exp
DSL Broadband Exp
Microsoft A+ Cert
Spotwave Certified Installer
CEDIA Experience
Certified Wireless Network Adm
CISCO Experience
Crestron Exp
CrossMatch LSMS Exp
DSL Broadband Exp
Spotwave Certified Installer
Misc. Licenses - Please select all that apply:
OSHA Training Completed
SeaTel Certification
Security Clearance
Satellite - Please select all that apply:
BICSI Certification
C-Band Satellite Exp
Microwave Antenna Experience
Viasat Linkstar Exp
Off Air Experience
Wildblue Certification
SBCA Level 1 Certification
Starband Certification
BICSI Certification
C-Band Satellite Exp
Microwave Antenna Experience
Viasat Linkstar Exp
Off Air Experience
Wildblue Certification
SBCA Level 1 Certification
Starband Certification
Broadband Satellite Exp
HNS Directway Certification
Hughes VSAT Certification
iDirect Experience
Mobile VSAT Experience
RF Experience
SBCA Level 3 Certification
Spacenet Experience
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
Appliance / TV Repairs - Please select all that apply:
Washers
Dryers (Electric)
Dryers (Gas)
Refrigerators
Freezers
Stoves/Ranges (Gas)
Stoves/Ranges (Electric)
Microwaves
Portable A/C
Sealed Systems
Dishwashers
LCD TV
Plasma TV
LED TV
DLP TV
Monitors
Computers
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:
06302021 - Credit Card Authorization Form
11082017 - Background Check Authorization Form
Service Provider Agreement June 2021
Service Provider Policy and Procedures Acknowledgement June 2021
W9
For Reference Only:
Code of Business Ethics June 2021
Inventory Management Policies June 2021
safety handbook full version June 2021
Service Provider Procedure June 2021
USSI - Sample COI
By entering your name here you hereby agree that all information entered is true and accurate.
Clear
Submit