Roof-A-Cide® APPLICATION FORM

SECTION I --- PROFILE
Name:
Company Name:
Address:
City:
State:
Zip:
Phone:
Fax:
E-mail Address:
Website Address:
(If not a company) Present Occupation, Key Skills and/or positions held:
Territory or Territories Requested: Please indicate by: State, County and Zip Code
Do you wish to become a Licensed Applicator or Distributor?	Licensed Applicator Distributor
SECTION II --- Classification
Roofing Company
Roof Cleaning Company
Both
Individual
SECTION III --- BUSINESS TYPE Please complete this section where applicable

ROOFING COMPANY

How many years has your company been Installing Roofs	yrs
How many Roofs do you Install in an average year
How many Roofs did you install year-to-date?

ROOF CLEANING COMPANY

How many years your company been Cleaning Roofs?	yrs
How many Roofs do you Clean in an average year?
How many Roofs have you Cleaned year-to-date?
How are your currently Cleaning Roofs? Please include what solutions are used.
What is your Pricing Per Sq. Ft.

INDIVIDUAL

Do you presently have a company and if so the type of business and your primary area of expertise?
How long has your PRESENT company been in business?	yrs
Do you intend to use this firm for this business	Yes No

SECTION IV --- REQUESTED GENERAL ADDITIONAL INFORMATION

What is the combined size of your past and present customer base?
What % of that customer base do you believe would be interested in prevention of “Roof Algae”	%
How many customers do you service on a contract basis?
Do you currently carry Liability Insurance for the company and its employees?	Yes No
How many full-time employees does your company have?
How many part-time employees does your company have?
How many service vehicles does your company operate?
What Associations does your company belong to?
What percentage of your business is:
Residential %	%
Commercial %	%
Light Commercial %	%
Industrial %	%
Please describe your primary areas of expertise?
Please explain in a few words your primary reason for your interest in this opportunity?
Bank Affiliation:
Does your bank provide your company with a credit line?	Yes No

Please be sure you have filled in all applicable fields and then press submit!
THIS DOCUMENT IS CONSIDERED CONFIDENTIAL - BEARER HAS RESPONSIBILITIES The contents of this application/document are for the sole and confidential use for qualification evaluation purposes only by Sunrise Roof-A-Cide® Sales, Inc. (an Authorized Distributor of Roof-A-Cide®, Inc.) and Roof-A-Cide®, Inc. to which it has been provided. The information herein may not be reproduced or distributed in any way without the prior written permission of the aforementioned company and/or individual who has provided it. [Top of Page]