NJContractorConnection.com
CONTRACTOR MEMBERSHIP FORM

General Information

Company Name *
Owners Full Name *
Please include middle name when applicable.
Owners Date of
Birth *

MM		/
DD		/
YYYY
Primary Contacts Full Name *
Please include middle initial.
Additional Owners/Partners/Shareholders Full Names
Please list all owners/partners/shareholders.
Business Phone Number *

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Cell Phone # *

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Fax #

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Email *
Confirm Email *
Website
Business
Address *

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Home
Address

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Please write "same" if your home address is the same as your business address.
Counties Served *
 Sussex 
 Passaic 
 Bergen 
 Warren 
 Morris 
 Essex 
 Hudson 
 Hunterdon 
 Somerset 
 Union 
 Middlesex 
 Mercer 
 Monmouth 
 Ocean 
 Burlington 
 Camden 
 Gloucester 
 Alantic 
 Cumberland 
 Cape May 
 All Of New Jersey 
Please check off all the counties you service. If you service all of NJ check that box only.
Company
Description *
Please let us know what your customers should know about your business.
Services *
 Air Conditioning Repair/Installer 
 Additions/Add-A-Level 
 Alarm & Security Systems 
 Asphalt Driveways 
 Bathroom Remodeling 
 Basement Remodeling 
 Basement Waterproofing 
 Custom Decks 
 Custom Homes 
 Custom Trim 
 Custom Cabinits 
 Electrical  
 General Contractor 
 Hardwood Floors 
 Heating and Furance Repair/Install 
 Kitchen Remodeling 
 Landscape Design/Build 
 Masonry 
 Painter 
 Paver Stone Installer 
 Pool Installer 
 Roofer 
 Sheetrocker 
 Siding 
 Solar Installation 
 Tile Floors 
 Window/Door Replacements 
 Other 
If you checked "Other" please describe below.
Other Services
Number of Employees *
Including the Owner.
Years in
Operation *
3 years minimum required for approval
Are you a Family Owned business? *
 Yes 
 No 
Are you a Owner Operated business? *
 Yes 
 No 
Do you use Subcontractors?
Do you offer a Guarantee?
How Long is your Guarantee? *
Are you Bonded? *
 Yes 
 No 
Amount of the Bond?
Do you offer 24 Hour/Emergency Service? *
 Yes 
 No 
Do you offer a Senior Discount? *
 Yes 
 No 

License Information

Please list all relevant licenses.
Is the business appropriately Licensed? *
 Yes 
 No 
How many
Licenses? *
 1 
 2 
 3 
 4 or more 
1. License Type & Number *
2. License Type & Number
3. License Type & Number

Insurance Information

Please be accurate.
Insurance Carrier's Name *
Insurance Policy Number *
Insurance Carrier's
Phone # *

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Upload a File
Please send us a copy of your Insurance .

Certifications

Please list all the relevant certifications.
Are You Lead Abatement Certified by the state of NJ? *
 Yes 
 No 
Other Certifications *
Please list all relevant certifications.

References

Please provide 3 names and phone numbers.
Name *

First
Last
Phone Number *

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Name *

First
Last
Phone Number *

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Name *

First
Last
Phone Number *

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Who refered you to us? *
If you checked "Other" please describe below
If you checked "A NJCC Contractor" please leave their full business name below.
If you checked "Internet Listing Site" please name which site.
Other
I confirm that the information contained here is true and accurate, and that I am an authorized representative of this company. I acknowledge and understand my responsibilities under the NJ Contractor Connection Terms of Service Agreement. *
 Yes 
 No 
Name

First
Last
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