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Kaput Inc. is seeking Roadside Assistance Partners .We are an application based service company, partnering with individuals and companies to provide On Demand roadside assistance.
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1
Name
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Please enter your name and middle initials.
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2
Phone
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Area Code
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3
Email
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example@example.com
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4
Address
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Street Address
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City
State / Province
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Afghanistan
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Algeria
American Samoa
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Angola
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Antigua and Barbuda
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Cote d'Ivoire
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Kiribati
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Kuwait
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Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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5
Drivers License #
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DL
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6
Date of Birth
/
Date of Birth
Month
Day
Year
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7
Issuing Province
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8
Expiry Date
*
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Expiry Date
Day
Month
Year
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9
Drivers License Image
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Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Upload Image
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10
Primary Service Location
*
This field is required.
Winnipeg, MB
Brandon, MB
Steinbach, MB
Thompson, MB
Portage La Prairie
Winkler
Selkirk
Morden
Dauphin
The Pas
Flin Flon
Stonewall
Niverville
Neepawa
Oakbank
Altona
Swan River
Virden
Beausejour
Carman
Minnedosa
Gimli
Killarney
Ste. Anne
Morris
Souris
Stony Mountain
Carberry
Boissevain
Roblin
Shilo
Russel
Rivers
Arborg
Teulon
Winnipeg Beach
Lac du Bonnet
Melita
Ste. Rose du Lac
Regina, SK
Saskatoon, SK
Lloydminster, SK
Moose Jaw, SK
Winnipeg, MB
Brandon, MB
Steinbach, MB
Thompson, MB
Portage La Prairie
Winkler
Selkirk
Morden
Dauphin
The Pas
Flin Flon
Stonewall
Niverville
Neepawa
Oakbank
Altona
Swan River
Virden
Beausejour
Carman
Minnedosa
Gimli
Killarney
Ste. Anne
Morris
Souris
Stony Mountain
Carberry
Boissevain
Roblin
Shilo
Russel
Rivers
Arborg
Teulon
Winnipeg Beach
Lac du Bonnet
Melita
Ste. Rose du Lac
Regina, SK
Saskatoon, SK
Lloydminster, SK
Moose Jaw, SK
Select your base location.
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11
Secondary Service Location
*
This field is required.
Altona
Arborg
Beausejour
Boissevain
Brandon, MB
Carberry
Carman
Dauphin
Flin Flon
Gimli
Killarney
Lac du Bonnet
Melita
Minnedosa
Morden
Morris
Neepawa
Niverville
Oakbank
Portage La Prairie
Rivers
Roblin
Russel
Selkirk
Shilo
Souris
Ste. Anne
Ste. Rose du Lac
Steinbach, MB
Stonewall
Stony Mountain
Swan River
Teulon
The Pas
Thompson, MB
Virden
Winkler
Winnipeg Beach
Winnipeg, MB
Regina, SK
Saskatoon, SK
Lloydminster, SK
Moose Jaw, SK
Altona
Arborg
Beausejour
Boissevain
Brandon, MB
Carberry
Carman
Dauphin
Flin Flon
Gimli
Killarney
Lac du Bonnet
Melita
Minnedosa
Morden
Morris
Neepawa
Niverville
Oakbank
Portage La Prairie
Rivers
Roblin
Russel
Selkirk
Shilo
Souris
Ste. Anne
Ste. Rose du Lac
Steinbach, MB
Stonewall
Stony Mountain
Swan River
Teulon
The Pas
Thompson, MB
Virden
Winkler
Winnipeg Beach
Winnipeg, MB
Regina, SK
Saskatoon, SK
Lloydminster, SK
Moose Jaw, SK
Press the Ctrl key and select locations.
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12
Services you could like to provide (Based on your vehicle)
*
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Towing
Tire Changing
Battery Boost
Fuel Delivery
Lockout Service
Winching
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13
Type of service vehicle.
*
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1/2 ton truck
3/4 ton truck
Tow truck
SUV
Sedan
Motorcycle
1/2 ton truck
3/4 ton truck
Tow truck
SUV
Sedan
Motorcycle
Vehicle being used for the service
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14
How did you hear about us?
*
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Google
Facebook
Instagram
Indeed
Friend
Other
Google
Facebook
Instagram
Indeed
Friend
Other
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15
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