Join Golden Providers | Golden Providers

Thanks for joining Golden Providers!

Step One – Review & Agree to our Member Code of Ethics:

Step Two – Submit Golden Providers Membership Application Online:

Go to Person:

First

Last

Your Direct #:

Business:

that it Providers

Address (with City/State/Zip):

Business Phone:

Cell Phone:

Fax Number:

Web Address:

Position:

For How Long?

Occupation

Full Time
Part Time

Product/Service Description

(suggested description of Product/Service as it will appear on the Directory/Web)

Licenses/Certifications/Boards (Please Specify):

City/County/State License(s)
Certification(s)
Business Card

Please scan and email any speific items noted to: Info@GoldenProviders.com.

Past Experience in Field/Occupation:

Related Experience & Background - Please scan and email additional page(s) if necessary

Your Education/Background in Field/Occupation:

Related Experience & Background - Please scan and email additional page(s) if necessary

Have you ever been convicted of a felony or have there ever been any successful judgments or lawsuits against your company?

If Yes above, please explain:

Reference #1 (Name / Phone / Email)

Reference #2 (Name / Phone / Email)

Reference #3 (Name / Phone / Email)

I authorize the verification of the information provided on this form. By adding my name in the signature block below, I verify that my business meets and will abide by the code of ethics. It is my due diligence to bring it to the attention of the board of directors if, at any time, my business fails to meet any of the requirements to be a member of Golden Providers. Membership may be subject to termination if I fail to meet any of the following or have a breach in coverage. I have retained a copy of this application for my records. I acknowledge that Golden Providers requires Members to provide Business/Professional License (when applicable), Active Business Insurance (where applicable) and to be in good standing with the Better Business Bureau.

Signature (Full Legal Name) & Date Signed

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