Business Name:
_________________________________________________________
Description:
___________________________________________________________
Contact Name:
__________________________________________________________
Physical Location:
_____________________________________________________
Mailing Address:
_______________________________________________________
_______________________________________________________
Town/State/Zipcode:
____________________________________________________
Phone:
____________________________ Fax: _______________________________
E-mail address:
________________________________________________________
Web Site Address:
______________________________________________________
Category - Please select one from
the following:
___ Agriculture, Nurseries, Farms
___ Hair Stylists and Tanning
Salons
___ Architecture
___ Health Care Services
___ Arts and Crafts
___ Insurance
___ Automotive - Sales, Service,
___ Manufacturing Businesses
Rentals,
etc.
___ Building Supplies and Hardware
___ Municipal
___ Business Services
___ Newspaper
___ Computer and Internet Services
___ Real Estate
___ Convenience Stores
___ Recreation and Entertainment
___ Financial Services
___ Restaurants and Lodging
___ Florist
___ Retail Stores
___ Fuel, Heating - Sales and
Service ___ Small Engines - Sales and
Service
___ Furniture - Sales, Repair,
___ Trucking
Upholstery
___ Grocery Stores
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Check # ______________________________
Date _________________________
Signature
______________________________________________________________