Application

PAN GREGORIAN ENTERPRISES COOPERATIVE OF UPPER NEW YORK, INC

MEMBERSHIP APPLICATION QUESTIONAIRE

Please check one of the following

ITEMS IN RED ARE REQUIRED

APPLICANT’S NAME:
(name of establishment applying for membership)

BUSINESS ADDRESS
(please write the physical address of the business and the mailing address, if they are different)

Physical Address:

Mailing Address:

County:

TELEPHONE NUMBER(S):*

FAX NUMBER:

E-MAIL ADDRESS:

WEB SITE:

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

BUSINESS OWNERSHIP CATEGORY:
 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

DO YOU CURRENTLY BELONG TO ANOTHER PURCHASING GROUP?
 YES
 NO

If yes, which one:

BUSINESS CORPORATION NAME:

OWNER(S) NAME:

TYPE OF BUSINESS i.e. (Diner/restaurant/etc…)

YEARS IN BUSINESS:

CAPACITY OF ESTABLISHMENT:

CONTACT PERSON:*

TITLE:

PHONE#:*

BEST TIME TO CALL:

SECONDARY CONTACT INFORMATION (Other than Establishment)
ADDRESS:

PHONE#(s):

CONTACT NAME:

WHO ARE YOUR CURRENT SUPPLIERS?

ARE YOU USING PEPSI-COLA?:
 YES
 NO

IF YES, ARE YOU CURRENTLY UNDER AN INDIVIDUAL PEPSI CONTRACT?:
 YES
 NO

IF NO, WHO IS YOUR CURRENT BEVERAGE SUPPLIER?:

APPROXIMATELY GROSS ANNUAL PURCHASE:

How did you hear about Pan Gregorian Enterprises and/or who referred you to us?

I, OWNER/PARTNER, HEREBY AGREE THAT ALL THE ABOVE ANSWERS ARE ACCURATE.
 YES