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2nd part
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A. Type of Store(s) (Complete the following):

                         # of Stores   Avg. Selling
   sq/ft/store		   # of Checkout
  Aisles Per Store		  Avg. Weekly
    Open Hrs
Conventional Supermarket  ________   ________     ________   ________
Combination (Super) Store  ________   ________     ________   ________
Warehouse  ________   ________     ________   ________
Small Grocery  ________   ________     ________   ________
Convenience Store  ________   ________     ________   ________
Pharmacy Only  ________   ________     ________   ________
Department Store  ________   ________     ________   ________
Liquor Store Only  ________   ________     ________   ________
Restaurant Only  ________   ________     ________   ________
Pet Food Dealer  ________   ________     ________   ________
Gasoline Service Station  ________   ________     ________   ________
Other (Describe)______________________________________________

B. Check Applicable Product Categories Stocked:

___Baby food___Prepared foods___Produce
___Baking mixes & needs___Soft drinks___Delicatessen
___Candy & gum___Soups___Fresh bakery
___Cereals___Sugar & syrup___Cigarettes, tobacco
___Coffee,tea & cocoa___Household supplies___Liquor, excld wine/beer
___Condiments___Paper products___Beer
___Crackers & bread products___Pet foods & products___Wine
___Diet foods___Soaps & detergents___Pharmacy
___Canned fish & meat___Health & beauty aids___Apparel
___Canned fruit & vegetables___Dairy___Automotive supplies
___Snacks___Fresh meat___Hardware
___Salad dressings, mayo, oil ___Packed meat___Other general merch.
___Frozen foods
COUPON DATA:
A. Estimate average dollar value of weekly coupon redemption: $___________
B. Coupon submission frequency: ___weekly ___monthly ___quarterly
C. How are coupons submitted? ___direct to manuf. ___clearinghouse ___wholesaler
    Name:______________________________________________________________
    Address:____________________________________________________________
D. Contact person for coupon redemption:___________________________________
Owner/managers certification: I hereby certify that all the information provided in the application is correct to the best of my knowledge.
Signed (Mandatory):__________________________Title:________________________
Printed Name:________________________________Date:______________________
Signed (Mandatory):___________________________Printed Name:__________________
Title:______________________________________ Date:___________________________