Specialized Vendor Application

Company Name: *

Please list name(s) of Registered Business Owner(s): *

Please provide the Company's Physical Address (no P.O. Boxes accepted): *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Contact Person for GTJ: *

First

Last

Primary Contact Phone #: *

Primary Contact Email Address: *

Please select your business type as registered with the government: *

W9 upload: *

Drag & Drop Files, Choose Files to Upload

Valid file type .pdf

Certificate of Insurance upload: *

Drag & Drop Files, Choose Files to Upload

Valid file type .pdf

Please describe licenses and/or certifications carried by company: *

General comments / Additional information:

Phone