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*