Agent Application Form

Company Name:*

Business Address:*

Postcode:*

Contact Name:*

Contact Number:*

Fax Number:

E-mail Address:*

Website Address (if Applicable):

Date Company Started Trading:*

Company Registration No. (if Applicable):

Enter VAT Number if applicable:

Please enter Insurance Co. Name, Policy Number and Expiry date:*

Enter value of your Public Liability Insurance:*

Number of Engineers:*

Appliances you Repair: Washing Machines

Tumble Dryers

Washer Dryers

Refrigerators

Freezers

Fridge / Freezers

Side by Side Refrigeration

System Re-gas

Dishwashers

Microwaves

Cooker Hoods

Electric Ovens

Electric Hobs

Gas Ovens

Gas Hobs

Corgi Registered

Please list seperatly all Postcodes covered (e.g. B1, B2):*

Please enter Manufacturers / Work providers who you currently work for:*

If you are Corgi Registered then please enter you number
here:

Expiry Date

Gas Safe Number

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