university Mall

Applicant:

Address:

City:

State: Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas (except Canada) Armed Forces Europe, Canada, Africa, Middle East Armed Forces Pacific California Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

Home Phone:

Business Phone:

Email Address:

Company Name:

Name for Sign (DBA):

Type of Space Required: Cart Kiosk In-Line

Merchandise to be Sold:

Price Points:

Projected Monthly Sales:

Have you had prior retail ⁄ experience? Yes No

If yes‚ please list:

Is your concept seasonal or on-going? Seasonal On-going

Are you interested in other mall locations? Yes No

Signature: