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Name of applying company: *

Name of person applying: *

Corporate address: *

E-Mail: *

Phone number: *

Please check the below type of projects and/or applications your company is looking to serve with Epoxytec:MUNICIPAL WATER & SEWER PLANT STRUCTURESMUNICIPAL WATER & SEWER UNDERGROUNDNON-MUNICAPAL INDUSTRIAL PROTECTION

Please name one liaison for this ECAN program (this person will be responsible to uphold all training requirements, communication, standards, and requirements to stay current and prepared):

Please list the full names of certification seeking supervisors/foremen that will be present at all times when using Epoxytec products:

For how many years has your company applied coatings and/or performed rehab of concrete, please describe?

Does your company perform leak prevention, chemical grouting, or have they ever utilized hydraulic cements? Please be detailed in your description regarding experience in stopping leaks.

Is your company/crew well versed and experienced with mortar applications with a hand-applied trowel? Has your company ever sprayed cementitious materials with gunite/shotcrete equipment? Describe:

Describe the type of coating applications your company is familiar with, and the products you have applied:

Do you own any spray equipment? If so, describe the equipment you own?

What preparation equipment do you have available (owned)? (Abrasive blasting, water blasters, jetters, etc.). If utilizing water, at what psi and/or rate. Please be detailed