MMV Service Provider Application
Mount Mansfield Villages is a nonprofit organization dedicated to helping older adults remain in their homes. We are compiling a directory of recommended service providers who could serve our members in Cambridge, Underhill, and/or Jericho. If you would like to be listed in this directory, please complete the form below.

Thanks!

If you'd rather fill out a paper form than this online form, please click tiny.cc/mmvprop and then print, complete, and mail the form.

Name of Company *
Your answer
Contact first name *
Your answer
Contact last name *
Your answer
Phone *
Your answer
Email *
Enter "N/A" if you don't have email
Your answer
Website *
Enter "N/A" if you don't have a website
Your answer
Street Address or PO Box *
Your answer
City/Town *
Your answer
State *
Your answer
Zip *
Your answer
List the type(s) of service(s) your company can provide *
Your answer
Would you consider offering a discount to our members? *
If so, what percent? *
If no discount, enter "N/A"
Your answer
Please list any details about the discount *
If no discount enter "N/A." If you'll offer a straight percentage discount on everything, enter "Straight"
Your answer
Reference 1
Note: We will contact your references as part of our vetting process
Name of your first reference *
Your answer
Phone of your first reference *
Your answer
Email of your first reference *
Enter "N/A" if your reference has no email
Your answer
Reference 2
Note: We will contact your references as part of our vetting process
Name of your second reference *
Your answer
Phone of your second reference *
Your answer
Email of your second reference *
Enter "N/A" if your reference has no email
Your answer
Reference 3
Note: We will contact your references as part of our vetting process
Name of your third reference *
Your answer
Phone of your third reference *
Your answer
Email of your third reference *
Enter "N/A" if your reference has no email
Your answer
How many employees do you have (not counting yourself)? *
Your answer
Do you carry liability insurance? *
Are you bonded? *
Do you have one or more state licenses or professional certificates? *
If Yes, please list those licenses or certificates *
If No, please enter "N/A"
Your answer
How long have you been in business *
Check ALL the towns you service *
Required
Check ALL the ways members can request your service *
Required
Do you provide free estimates? *
Check ALL the forms of payment you accept *
Required
Do you have any questions and wish to be contacted by MMV? *
Reminder
Please email your insurance certificate to mountmansfieldvillages@gmail.com or mail it to Mount Mansfield Villages, PO Box 31, Underhill Center, VT 05490.
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