Vendor type:

□ Food

Please enter food vendor number___________________________________

Policy number and insurer ________________________________________

□ Non-food

Please enter your business license number ___________________________

Insurance number and insurer ______________________________________

Name : ________________________________________________________

Organization : __________________________________________________

Address : ______________________________________________________

_______________________________________________________

City : _________________________________________________________

State/Province : _________________________________________________

Zip/Postal Code : ________________________________________________

Country : ______________________________________________________

Home Phone : __________________________________________________

FAX : _____________________________________________

E - Mail : __________________________________________

Please fill out what Products or services you are providing :

______________________________________________________________

______________________________________________________________

______________________________________________________________

10 X 10 Space - 10 X 20 Space - 20 X 20 Space - Electricity

Method of Payment : ____________________

Date : ________________________

Signature : ___________________________________________

Read guidelines before you sign !

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