--HAIL TEAM APPLICATION--

Company Name:

Contact Name:

Phone:

Fax:

Other:

Address:

City:

State: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

IMPORTANT INFORMATION:  You must have general liability insurance!

Name of Carrier:

Amount of Coverage:

In what year did you begin providing PDR Services?

I hereby agree, that the above stated information is accurate to the best of my knowledge and

understand, that this information is to qualify above stated company and/or individual, as a

reputable service provider in the PDR field, for the Dent Network Hail Team.  It is also understood

and agreed, that this information will not be sold or distributed.

Yes:

No:

In addition, you also agree and understand, that this application does not guarantee or make any

promises, to assignment of work on the Dent Network Hail Team, and that each company and/or

individual, must be certified.

Yes:

No:

Your Email Address: