| (Please complete both sides of form, print or type
legibly and FAX forms to us at 423-5387.) |
| Exact, Legal Business Name: |
| D/B/Z/(s) |
| PO Box: |
| City, State, Zip: |
| Business started date |
| List all store acn/or warehouse locations (indicate
"none" if applicable, or list on attachment) |
| . |
| . |
| Telephone No: (_____) ________________ Fax
No: (___) _____________________________ |
| Facility owned or rented? ___________________ If
rented list landlord(s) name, address and telephone: |
| . |
| Accounts Payable Contact: |
| Federal Tax identification/social Secureity ID
Number |
| Tax Exempt? _______ no______ Yes
Number______________ (Attach copy of exemtpion caertificate) |
