Name_____________________________________________________________
Company Name_____________________________________________________
Address____________________________________________________________
City and State_____________________________________Zip Code__________
Website____________________________Facebook________________________
Merchant Circle Y N Phone_________________________________________
Email________________________________
Type of Equipment to be located:
___________________________________________________________________
___________________________________________________________________
General Product Pricing
___________________________________________________________________
Do you do Healthy Vending for schools Y N
If yes do you carry the items listed for the California Nutritional Program?
Y or N
Do you do commission accounts. Y N
Products Offered
Cans Y N Bottles Y N Food Y N Coffee Y N Snacks Y N
Areas
Use zip code, telephone prefix, city names, county
___________________________________________________________________
___________________________________________________________________
When are you available for appointments.
___________________________________________________________________
Have you read our policy Y N Do you understand our fees Y N
You must have a PAYPAL account for billing and to receive any appointments
from us. Please give us the email linked to your paypal account.
Email for paypal____________________________________________________
____________________________________
Signed (electronic signature)
___________________
Date
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