When filling out the application, please type or print clearly. Incomplete applications will not be processed and may result in coupon redemption delays. Please mail to New Mexico Grocers Association,1182 Behnke Road, Los Lunas, NM 87031.
| 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):
| ________________________________________ | |
