SAVE up to 40% with a annual membership to LIFELINE ONLINE

Get started for a test drive.  Subscribe for 6 months to LIFELINE ONLINE
 
 

VENDOR/PROVIDER REGISTRATION FORM

PLEASE FILL OUT THE SERVICE PROVIDER
REGISTRATION FORM

 DOWNLOAD FORM
Service Provider Registration Form
 LIFELINE requires a completed SERVICE PROVIDER REGISTRATION FORM and *REQUIRED DOCUMENTS* with membership fees. 
Please fill out the information below.  All fields *ARE REQUIRED*.
Company Name:
Contact Name:
Address1:
Address2:
City:
State:
Zip:
Phone:
Fax:
Email Address: yourname@email.com
Website:
Services Offered
 CHECK ALL THAT APPLY		 LT DUTY TOWING MD DUTY TOWING H-D DUTY TOWING RECOVERY AUTO TRANSPORT
SPECIALIZED TRANSPORT TIRE SERVICE BODY SHOP REPAIR SHOP REPOSSESSION
LOCK OUTS PPI TOWING BASIC ROADSIDE REPAIR H-D REPAIR LIMOUSINE TOWING
FLEET: NUMBER OF TOW TRUCKS: 
DISCOUNT: IS YOUR COMPANY WILLING TO OFFER A 10% DISCOUNT TO LIFELINETOWING.COM USERS?  DISCOUNT APPLIES ONLY FOR NEW CUSTOMERS.  SIGN-UP DISCOUNTS HELPS GENERATE MORE SUBSCRIPTIONS AND LARGER CUSTOMER BASE.

Yes          No
COMMENTS:

      

*DISCLAIMER*
LIFELINETOWING.COM will not use your personal or business information or share your information with any outside resources without your expressed permission or outside the terms of the NATIONAL DISPATCH TOWING SERVICE.  LIFELINETOWING.COM values your personal privacy.  All information submitted is considered client confidential.  Thank you.

Copyright © 2008 Lifeline Inc. All rights reserved.