When filling out the application, please type or print clearly. Incomplete applications will not be processed and may result in coupon redemption delays. Please fax completed application to: 505-883-3197, or mail to New Mexico Grocers Association, 4010 Carlisle Blvd. NE Suite A, Albuquerque, NM 87107.
| GENERAL DATA: |
|
|
A. Present Name of Co./Division/Store:
| ________________________________________ | |
B. Co./Division/Store Mailing Address:
|
________________________________________
________________________________________
| |
C. Fax #: ________________________
| Phone #: _________________________ | |
D.Phys Address of Store:
| ________________________________________
________________________________________
| |
E. Liquor Lic #:____________________
| F. Fed Tax ID: ________________________ | |
G.____Proprietorship ____Division ____
| Corporation ____State of Inc. (check only one) | |
H.Coupons submitted by: ___single sto
(# of stores__)
| re, ___total Co. (# of stores__), ___division
| |
I.Company Trade Name or Store Name:
| ________________________________________ | |
J.Date Business Started/Acquired:
| ________________________________________ | |
K.Former Store Name (if Applicable):
| ________________________________________ | |
L.Suppliers (Wholesale): Name:
Address:
Telephone:
Customer #:
| ________________________________________
________________________________________
________________________________________
________________________________________
________________________________________
| |
Secondary Supplier Name:
Address:
Telephone:
Customer #:
| ________________________________________
________________________________________
________________________________________
________________________________________
________________________________________ | |
M. Estimated Gross Annual Sales:
| ________________________________________ | |
N. # of Employees (full & part time):
| ________________________________________ | |
