Company Name *

Scope of Work *

Location(s) of Service

Check all provinces that apply, list all areas applicable, if willing to travel to all areas with the province checked then please put ALL AREAS

Select Provinces of Service *

Alberta

British Columbia

Saskatchewan

Manitoba

All Areas

Province Areas of Service *

Write N/A if you service all areas

Safety Requirements

Please check all that your company currently has

COR Certified *

Yes

No

N/A

WCB *

Yes

No

N/A

Equipment Training (in class) *

Yes

No

N/A

SECOR Certified *

Yes

No

N/A

First Aid *

Yes

No

N/A

Fit Test and CWB (Welders) *

Yes

No

N/A

Proof of Insurance *

Yes

No

N/A

Fall Protection (in class) *

Yes

No

N/A

About Your Company

Years in business? How many Employees are working for the company? *

Additional Comments

Contact Information

Full Name *

Phone Number *

Email *