Instruction:
Please complete this form in its entirely. All blanks must be filled in. If information is not available or does not apply, please indicate N/A.

Today's Date

PMDG Representative Requesting Services

PMDG Project(s)/Client Name(s)

Consultant Primary Email

Website

General Information

Company Legal Name

DBA (If Applicable)

Business Address

City

State

Zip

Is the remittance address same as above ?

Remittance Address (Must be on W9)

City

State

Zip

Principal(s) (Name/Title)

Main Contact (Name/Title)

Telephone Number

Email Address

Accounting Contact Name

Telephone Number

Email Address

Financial and Legal Information

Company Status

Corporation

LLP/LLC

Partnership

Sole Proprietor

Individual

Date Established

EIN/SSN

Number of Regular Employees

Description of Services Provided

Is travel involved to provided services ?

Yes

No

Professional Registration(s)

Do you hold a Professional Registration ?

Yes

No

Client References

Please list three recent projects with a description of the services provided. Also provide the Client name and the date of service.

Client Name

Contact Name

Telephone Number

Date of Service

Description of Services Performed

Client Name

Contact Name

Telephone Number

Date of Service

Description of Services Performed

Client Name

Contact Name

Telephone Number

Date of Service

Description of Services Performed

Please upload W9

Insurance Inquiry

Please review PM Design Group's insurance requirements below, paying close attention to the amounts of coverage contain in the MSA. It will be that you submit a certificate of insurance as verification of coverage.

Are you able and willing to provide a certificate of liabilty insurance per PM Design Group's requirements?

Yes

No

Commercial General Liability
Professional Liability
Commercial Auto Liability
Workers' compensation and employers' liability
Supporting Documents

Review Master Services Agreement and NDA

Do you agree with the Master Services Agreement above ?

Yes

No

Company Questionaire

If applicable, select your company's diversity categories (Select all that apply):
If your company is a minority-owned business, please select one of the following:
If your company certified by any of the following certification agencies? (Select all that apply):

Name

Title

Date

Phone Number