Physical Location Mailing Address (if different)





TELEPHONE:* FAX:

E-MAIL: WEBSITE:

TAX ID: * APPLICATION WILL NOT BE PROCESSED WITHOUT THE TAX ID#

BUSINESS TYPE: CORPORATION PARTNERSHIP SOLE OWNER OTHER 

If OTHER, please describe:

LIST PERSON(S) OR ENTITIES, HAVING AN INTEREST IN THE BUSINESS. SPECIFY HIS/HER TITLE AND PERCENTAGE OF OWNERSHIP, IF ANY

NAME TITLE PERCENTAGE
A
B
C

DO YOU CURRENTLY BELONG TO ANOTHER PURCHASING GROUP? Yes No 

If yes, which one:

BUSINESS CORPORATION NAME:

TYPE OF BUSINESS:  diner club restaurant bar bagel shop deli bakery other

YEARS IN BUSINESS:
CAPACITY OF ESTABLISHMENT:

CONTACT PERSON:*
TITLE: