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.
* Required
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?
*
Yes
No
Maybe
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?
*
Yes (Please provide certificate)
No
Are you bonded?
*
Yes
No
Do you have one or more state licenses or professional certificates?
*
Yes
No
If Yes, please list those licenses or certificates
*
If No, please enter "N/A"
Your answer
How long have you been in business
*
1 year or less
2 to 5 years
6 to 10 years
11 or more years
Check ALL the towns you service
*
Cambridge
Jericho
Underhill
Required
Check ALL the ways members can request your service
*
Phone
Email
Text message
Required
Do you provide free estimates?
*
Yes
No
Check ALL the forms of payment you accept
*
Cash
Checks
Credit cards
Required
Do you have any questions and wish to be contacted by MMV?
*
Yes
No
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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