Contractor Application

Company Information

Company Name:*

Address:*

(No PO Boxes)

City:*

State:*

Zip:*

Sales Phone:*

Website:

Sales Email:

User Login:*

Password:*

Confirm Password:*

Security Question:*

Answer:*

Contact Information

First Name:*

Last Name:*

Title:

Email Address:*

Phone Number:

How did you hear about us?*

Qualifying questions

Have you sold/installed Modine Heaters in the past 12 months?*

Do you accept service calls on Modine heaters your company did not sell/install?*

Distance willing to travel in miles?*

Yes, I agree to your terms and conditions*
(Terms and Conditions)
* Required

Additional Company Information

Who is your preferred Distributor?

Brief Company Description:

Hours of Operation:

Time Zone:

–

–

Thank you for your interest in becoming a Modine Authorized Contractor

Based on the following responses we are unable to approve your application at this time:

Would prefer not to service or install Modine units that were not purchased through .

If you have any questions regarding your application, please call 1-800-828-HEAT or email bhvaccontractors@modine.com

Thank you for your interest in
becoming a Modine Authorized Contractor

Your application has been approved and you will receive an email shortly
to confirm your enrollment in our Authorized Contractor Program.

If you have any questions prior to receiving your confirmation email, or you do not receive this email,
please call 1-800-828-HEAT or email bhvaccontractors@modine.com

Original Values
City	State	Zip


Possible Alternatives
City	State	Zip