Qt Capital Vendor Application – Qt Capital Investments LLC

Business Name

Contact Name

First

Last

Phone Number

Email Address

Business Address

Address Line 1

Address Line 2

City

State

Zip Code

Services Offered

Service Areas

Years of Experience

Emergency Availability

Yes
No

License Number

Insurance Provider

Insurance Coverage Status

Meets Qt Capital Insurance Requirements
Does NOT meet Qt Capital Insurance Requirements

Insurance Waiver & Limited Vendor Acknowledgment

Insurance Waiver Agreement

I acknowledge and agree to the Insurance Waiver and Limited Vendor terms.

Type Full Name (as Signature)

W-9 Upload

Drag & Drop Files, Choose Files to Upload

Proof of Insurance Upload

Drag & Drop Files, Choose Files to Upload

License or ID Upload

Drag & Drop Files, Choose Files to Upload

Owner Name

First

Last

Acknowledgment Insurance

Phone Number

Billing Contact

First

Last

Phone

Vendor Agreement Qt Capital Investments, LLC

By submitting this vendor application, the vendor agrees to perform work professionally, maintain insurance, obtain approval before work unless emergency, and submit accurate invoices. Vendor is an independent contractor.

Agreement

I agree to the Vendor Agreement for Qt Capital Investments, LLC

Type Full Name (as Signature)