Membership Application

Legal Business Name
Doing Business as:
Federal ID #
Physical Address
Street AddressAddress Line 2CityStateZIP Code
Different Shipping Address?
- Yes, My Mailing Address is different than my shipping address
Mailing Address
Street AddressAddress Line 2CityStateZIP Code
Mailing Address
Street AddressAddress Line 2CityStateZIP Code
Phone
Fax
Email
Number of Locations
Location Information*
Complete for each of your store's locations
Supplier #of Check Out Lanes Annual Non-Gas Sales Volume Square Feet Number of Employees Number of Pumps
MFDA Programs of Interest to Your Business
Note:
-Workers Comp insurance is required by law.
-Group Health Insurance is for groups of 50 or more.
-No Minimum coupon count or value.
- "Comp Watch" (Workers Comp Insurance)
- Group Health Insurance
- Property / Casualty Insurance
- Phone Service Program
- Coupon Redemption Service
Owner / Manager Signature*
By typing your name here, you are signifying that all of the information given above is accurate and complete to the best of your knowledge, and you are aware that the information given above will remain confidential, and used only to improve and expedite member services.