Step 1 of 3 33% Date MM slash DD slash YYYY Your Name* First Last Email address(Required) Mobile Phone*(Required) Full Company Legal Name(Required) FEIN # of Employees*(Required) Your Position*(Required)Please SelectOwner / CEOCo-OwnerVice PresidentSenior Executive / ManagerOtherName of Company President (if not you) Company Website Address Office Phone*Address Street Address City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have a company Facebook or LinkedIn page? Facebook LinkedIn Both Neither Facebook Page link:(Required) Linkdin Page link:(Required) Do you have salespeople on staff?(Required) Yes No How many?(Required) YesNo Do you have any independent salespeople?(Required) Yes No Total company annual revenues:(Required) Annual revenue from energy efficiency projects (if applicable):(Required) Annual revenue from existing customers with electric/gas/other services (if applicable):(Required) What is the sales/service territory you currently cover?* Do you have a safety program? Yes No Is your business currently bonded? Yes No Services Provided (check all that apply)(Required) Electricity Services Gas Services Lighting Upgrades HVAC Refrigeration Mechanical Electrical Upgrades Control Systems Solar Something Else / Other What professional memberships are you currently a member? What vertical market(s) do you currently have existing clients (choose all that apply):(Required) Residential Customers Hospitality Grocery Commercial Buildings Municipal / Institutions Restaurants Healthcare Multi Family Properties Education Other If Other Please Explain: Who other than yourself is authorized to sign legally-binding agreements on behalf of your company? Please complete this form (all fields are required). What is the main reason you want to become a Partner with us? (choose all that apply)*What is the main reason you want to become a Partner with us? (choose all that apply)(Required) I am searching for new and creative ways to improve my sales results I want to expand my current service offerings to my existing and future clients I heard about Origyn and was curious to learn if maybe we could work together I have active projects right now that I need assistance with in finding alternative funding sources Please provide any additional comments that you think we should know about you:(Required)Consent(Required) By checking this box, you attest that you are an officer of the company and the information provided in this application is accurate and provided without omission to the best of your knowledge. 49166
