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2. Vending Business Information
4. Business Name:
6. Mailing Address
8. City:
9. State:
10. Zip Code:
12. Phone:
13. Email:
15. Location of Vending Machines
17. Business Address:
19. Type of Vending
    -- Select One --Lotto MachineAir PumpGumballSoda/Snack
20. Vending Machines
    (How many vending machines)
24. Business Address:
26. Type of Vending
    -- Select One --Lotto MachineAir PumpGumballSoda/Snack
27. Vending Machines
    (How many vending machines)
31. Business Address:
33. Type of Vending
    -- Select One --Lotto MachineAir PumpGumballSoda/Snack
34. Vending Machines
    (How many vending machines)
38. Business Address:
40. Type of Vending
    -- Select One --Lotto MachineAir PumpGumballSoda/Snack
41. Vending Machines
    (How many vending machines)
45. Business Address:
47. Type of Vending
    -- Select One --Lotto MachineAir PumpGumballSoda/Snack
48. Vending Machines
    (How many vending machines)
52. I hereby certify that the above informatio is true and correct from the best of my knowledge and belief
54. Signature:
55. Date:
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56. 1. Receive an email copy of this form.
57. Email address

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