Authorized Installer Application Form

Company / Individual Information

Legal Business Name (or Individual Name)

DBA (if applicable)

Primary Contact Name

Title/Role

Email Address

Phone Number

Company Website (if applicable)

Years in Business / Installation Experience

Business Type

Please select the category that best describes you:

Independent Installer/Technician

Fleet Maintenance/Repair Provider

Upfitter

Mobile Installation Service

Location & Service Area

Primary Business Address

Service Region(s)

City

State

Zip

Do you offer mobile installation?

Technical Capabilities

Do you have experience installing electrical or CAN-based vehicle systems?

If yes, please list relevant experience or products installed:

Do you have diagnostic tools for J1939 or vehicle CAN bus?

If yes, list diagnostic tools/equipment:

Number of Installers/Technicians:

JakeLight Product Installation Interest

Which JakeLight product(s) are you interested in installing?

Estimated number of installations per month:

Do you plan to stock inventory?

Training & Certification

Would you like to participate in JakeLight installer training?

Preferred training format:

Do you require certification to meet customer or company policies?

Insurance & Compliance

Do you carry liability insurance?

If yes, coverage amount:

Are you willing to follow JakeLight installation standards and procedures?

References

Name

Company

Phone

Additional Comments

Please describe why you would like to become a JakeLight Authorized Installer:

Acknowledgment

By submitting this application, you acknowledge that JakeLight, LLC will review your information and may request additional documentation before approval. Approval is not guaranteed.