Business Name: Location Address: Billing Address: Type of Ownership: (check one) Sole Proprietorship Partnership Corporation Date Business opened: Number of Locations:   Tax Id Number: Description of Merchandise Sold: Do you take phone orders? Yes      No What %?   Name of Owner/Officer #1: Home Address: Social Security Number: Home Phone Number: Name of Owner/Officer #2: Home Address: Social Security Number: Home Phone Number: Business Phone: Fax Number: Description of Premise: Store Font Office Building Residence Average Ticket: Monthly Volume: