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Full Name
Email
Phone
State --Choose the state--TexasCalifornia
Tow From *
Job Type
---Choose the job type---Heavy Duty TowingFlatbed TowWheel Lift TowUnattended TowRescueMotorcycle TowCar LockoutJump StartBattery ReplacementFlat Tire
Date *
Last Name (required)
First Name (required)
Date of Birth (required)
SSN/Tax ID (required)
Street Address
City
State
Zip
Phone (required)
Secondary Number
Email (required)
Are you a United States citizen or legally authorized to work in the United States?
YesNo
Do you have a valid Driver’s license?
license number
Please attach a copy of your driver license Please attach a copy of your driver license. Accepted file types .doc | .docx | .pdf | .jpg | .jpeg, max file size 2MB
Do you have an active Tow Permit?
TDLR Copy Please attach a copy of your Tow Permit pocket card. Accepted file types .doc | .docx | .pdf | .jpg | .jpeg, max file size 2MB
Company name
DBA if any
Company Address
Company CA# license
Company Tow License Please attach your company Tow License. Accepted file types .doc | .docx | .pdf | .jpg | .jpeg, max file size 2MB
How many trucks do you own? Please write a number
What is your coverage area? What is the mileage radius your company coveres from your address?
Days & hours of operation Example: Mo-Fr 08:00-20:00. Please separete with , or new line
Liability $
Cargo $
Please attach a copy of your insurance certificate showing your coverages (required) Please attach a copy of your insurance certificate showing your coverages. Accepted file types .doc | .docx | .pdf | .jpg | .jpeg, max file size 2MB
I represent that the above information, and any other information I may be required to provide, is complete and accurate and any misstatement or omission may result in rejection of my application or termination of the contract. I authorize 10-4 Tow to conduct, at its discretion an investigative consumer report concerning my character, general reputation, personal characteristics and mode of living. Upon written request, additional disclosure concerning the complete nature and scope of the investigation will be provided. If I am contracted, I agree to comply with the policies, procedures, guidelines and standards of conduct of 10-4 Tow .
Signature * I understand and acknowledge that by checking the box below, I am legally agreeing to all of the statements in this document
