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Vending Locator Agreemen

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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