Vendor Profile

Please provide the primary and secondary contact information below. The contact information provided will be used to send notification and information regarding updates and changes.

Your Company Information

Company Name: Street Address: City: State: Zip: Website:

Primary Phone #: Office Fax #: Normal Business Hours: Federal Tax ID: Federal Tax Classification:

Name: Title: Email:

Password: Confirm Password:

Disclaimer

This system is QSI property and is provided solely for your convenience. Unauthorized access or use is prohibited and subject to civil suit or criminal prosecution. By using this system, you consent to QSI obtaining data internally or from third parties about any access, use, information and communications on the system. You acknowledge that your use is not private, and agree that all your information on, and usage of, the system may be monitored, recorded, retrieved, and used by QSI. You also agree to abide by all QSI policies for proper system use, and for protection of sensitive and export-controlled data.

All information accessed on the QSI Vendor website and placed on the site is confidential and subject to the existing confidentiality agreement between you and QSI. You are hereby advised that any dissemination, distribution, or copying of the information on the website without prior permission is prohibited. Giving out login names and/or passwords to anyone other than an authorized recipient is prohibited. If you believe that any of the above abuses have occurred, please contact QSI at 1-888-328-2454 immediately.

Primary & Secondary Business Contacts:Please designate the primary and secondary business owner/principal contacts. These individuals will receive important information and invitations via email regarding new business opportunities, seminars with our Field Partner Management team, and staff training and development tools.

Primary Contact:

Email: (do not use group email)

Phone:

Secondary Contact:

Email: (do not use group email)

Phone:

Contact Information

Scheduling Contact:

Email:

Phone:

Billing Contact:

Email:

Phone:

Owner/Officer:

Email:

Phone:

Emergency Services (after hours) Contact:

Email:

Phone:

Legal Status

Contractor License #: Please upload a copy (you may select more than one files to upload):

Special Status

Check any that apply and include a copy of your certification:

Services and Rates

Please contact the QSI Service Team at (316) 721-3656 if you need to adjust your rates, add/remove services, or change trip charges.
Please forward a service brochure if applicable in addition to the completed profile.
It is against QSI policy to sub-contract any work without the written consent of QSI.
QSI does not allow 2 men crews unless set forth in the work order.
Your rate must include tax.

Please supply all zip codes within your service area. You may only be considered for work located within the provided zip codes. A complete list will ensure you receive work orders for all areas covered. If applicable (separate multiple zip codes by commas):

You may use these links to determine and modify your preferred coverage area.

Additional zip codes to include:

Zip codes to exclude:

Signature

Your company rates will remain in effect until an updated Vendor Profile is submitted. All invoices for work accepted prior to an updated Vendor Profile must be billed at the rates set forth in the previous Vendor Profile which was in effect when the work was accepted. All work performed on behalf of QSI is subject to the Work Order, which incorporates by reference the Terms and Conditions applicable to Vendors.

By submitting this form, the undersigned confirms they are duly authorized to bind the company to the above listed conditions and rates

Name:

Signature:

Title:

Date: