MEMBERSHIP
APPLICATION
Company Name*
Number of Locations
Location Addresses*
Owner Name*
Owner Phone (Cell Phone Preferred)
Owner Email Address*
Shop Contact Name (if different than owner)
Shop Contact Phone (if different than owner)
Shop Contact Email (if different than owner)
Years in Business
Current DRP Programs by Center Ownership Structure
OE Certifications By Center
I-CAR Gold? YesNo
How did you hear about CCG?
What is your Refinish Brand? AxaltaAkzoNobelBASFPPGSherwin Williams
Refinish Reference* Please include your manufacturer reference (from Axalta, AkzoNobel, BASF, PPG, or Sherwin)
Distributor Who is your paint materials distributor?
Management System Utilized
Do you have any MSOs or Consolidators in your market? If so, provide names:
Why do you want to join CCG? Do you have a succession plan? If so, please explain
What industry programs do you participate in? Do you have any other affiliations? If so, please explain
Please include Two Insurer References* include name, phone and email for each
Date*
