Name of store:
Street address:
City:
County:
State:
Zip Code:
Type of store:
Number of locations:
Number of full-time employees:
Number of part-time employees:
Contact person:
Federal I.D. #:
Telephone:
Fax:
E-mail address:
Website address:
Workers' comp insurance expiration date:
Property and casualty insurance expiration date:
Name of owner:
Owner's home address:
City:
State:
Zip Code:
Telephone:
Services desired:	Credit card and debit card processing Gift Cards Health insurance Dental insurance Life and disability insurance Workers' compensation insurance Property and casualty insurance Electric Choice On-hold messaging service Internet services Other