Vendor Compliance Verification Form

Contact Information

Please indicate who is responsible for compliance administration

First name:

Last name:

Position:

Email:

Business Information

Please identify the service provider or contractor

Legal name of business:

Operating name is the same as legal name:

Yes

No

Operating name of business:

Address:

Address 2:

City/Town:

Province:

Postal code:

Country:

Main phone:

Fax:

Website:

Company Compliance Information

Please provide details for all applicable

Federal Tax Number:

This is your 9-digit Canada Revenue Agency Business Number or U.S. Employer Identification Number

Workers Insurance Number:

This is your Province or State Workers Compensation Board Account Number ( WCB / WSIB / CSST )

Contractor License Number:

This is your Municipal, Provinical or State issued license to perform work (where applicable)

Professional/Trade Registration:

This is your identification number from a legally recognized authority (where applicable)

Company Insurance Information

Please provide details for all applicable

Commercial General Liability Policy:

Name of Insurer:

Policy number:

Coverage amount: $

Excess or Umbrella Policy:

Name of Insurer:

Policy number:

Coverage amount: $

Automobile or Vehicle Policy:

Name of Insurer:

Policy number:

Coverage amount: $

Workers Insurance Policy (Private):

Name of Insurer:

Policy number:

Coverage amount: $

Broker/Agent:

Phone:

Email:

Worker Information

Please list all workers performing work on site; indicate whether they require a Certificate of Qualification (CQ)

First Name	Initial	Last Name	Job Description	CQ? Y/N
First Name	Initial	Last Name	Job Description	CQ Y N
First Name	Initial	Last Name	Job Description	CQ Y N
First Name	Initial	Last Name	Job Description	CQ Y N
First Name	Initial	Last Name	Job Description	CQ Y N
First Name	Initial	Last Name	Job Description	CQ Y N
First Name	Initial	Last Name	Job Description	CQ Y N
First Name	Initial	Last Name	Job Description	CQ Y N
First Name	Initial	Last Name	Job Description	CQ Y N
First Name	Initial	Last Name	Job Description	CQ Y N
First Name	Initial	Last Name	Job Description	CQ Y N

Acknowledgement

I, the undersigned, do hereby declare that the above information is true and complete to the best of my knowledge.

Name:

Signature:

Sign above

Dated: