Contractor Qualification Renewal Direct Payment Form V3 Contractor Qualification Renewal Direct Payment Form V3 Disclosures By submitting this renewal application, you reaffirm the agreements made upon your original application: Code of Conduct As an ASA Qualified Shotcrete Contractor we agree to ongoing compliance with the requirements and standards set forth in the ASA Shotcrete Contractor Qualification Program Description. We will not knowingly or purposefully violate any project specifications or requirements. We agree to maintain the required insurance coverage, staff our projects with trained and certified personnel, and strive to produce a high-quality product in a safe and professional manner. Agreement The ASA decisions concerning qualification, including but not limited to the decision of the CQC shall be final and binding; The applicant will not institute legal action of any kind to challenge those decisions; Neither the ASA nor its members, officers, employees or representatives (including but not limited to the members of the CQC) shall be subject to any claim for legal or equitable relief (including but not limited to money judgements and injunctive relief) arising out of those decisions; and, in any event, Neither the ASA nor its members, officers, employees or representatives (including but not limited to the members of the CQC) shall be liable for consequential or incidental damages of any kind as a result of the ASA Qualification program. The applicant further agrees that if it commences legal action in violation of this agreement, it shall be responsible for paying all costs and expenses, including attorney fees incurred by ASA and/or its members, officers, employees or representatives in the course of defending that legal action. Indemnification In the event that any party asserts a claim for personal injury, property damage, economic loss of other damages against ASA and/or its members, officers, employees or representatives arising out of or relating to the acts or omissions of an ASA Qualified Shotcrete Contractor, the ASA Qualified Shotcrete Contractor shall, upon request, defend and indemnify ASA and/or its members, officers, employees or representatives and hold them harmless from all damages, judgement, costs, losses and expenses, including attorney fees, resulting from said claim. Authorization I have read and agreed to the above disclosures. I authorize the verification of the information provided on this form and declare that it is accurate to the best of my knowledge. By submitting this application, I authorize my consent. I Agree * YesNo Date Submitted Renewal Fees Select Fee Option: * Member Renewal Fee - $1000 Non-Member Renewal Fee - $2000 Submit year and location of Convention for discount fee: Not Applicable2025 – Savannah, GA2024 – Lakeway, TX2023 – Ojai, CA2022 – Hilton Head, SC Billing Details Billing First Name * Billing Last Name * Billing Email * Billing Address * Billing Address Billing Address Billing Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country CC Number CC Number CC Number CC Number Month 123456789101112 CC Number Year 20262027202820292030203120322033203420352036 CC Number Submit If you are human, leave this field blank.
