National Automobile Club

Service Provider Application
Please complete and submit the application below for appointment as an official Service Contractor. If you have any questions, please call the NAC at 1-800-622-2136 or email us at ers@thenac.com.

CONTACT INFORMATION

* NAME:		* EMAIL:
* ADDRESS:		* CITY:
*STATE:		* ZIP:
* PHONE:		FAX:

COMPANY INFORMATION

* COMPANY NAME:
* CORPORATE TAX ID or SOCIAL SECURITY NUMBER:
INSURANCE CARRIER:
NUMBER OF YEARS IN BUSINESS:
TYPE OF BUSINESS:
NATURE OF BUSINESS:
OPEN 24/7:		YES NO
IF NO, PLEASE LIST YOUR HOURS:

NUMBER OF DISPATCHERS:
NUMBER OF TOW OPERTATORS:
NUMBER OF SERVICE OPERTATORS:
DO YOU HAVE:
LIGHT DUTY CAPABILITIES:		YES NO
MEDIUM DUTY CAPABILITIES:		YES NO
HEAVY DUTY CAPABILITIES:		YES NO
LOW CLEARANCE CAPABILITIES:		YES NO

ARE YOU CURRENTLY ON ROTATION WITH ANY POLICE AGENCIES?:
HIGHWAY PATROL:		YES NO
LOCAL PD:		YES NO
SHERIFF:		YES NO
TOTAL NUMBER OF TOW VEHICLES:
SLING/COMBO:
WHEEL LIFTS:
FLATBEDS:
SERVICE VEHICLES:
4X4:
PLEASE LIST MAKE, YEAR, RATING, AND CRANE CAPACITY FOR EACH VEHICLE AND ADD ANY ADDITIONAL COMMENTS:

Current Service Providers

Application