Warehouse/Distribution Center

Store Name

Store Number

Banner

Main Point of Contact

Email Address

Address

Contact Number

Who Will Be Responsible For Advertising Submissions?

Name

Email Address

Website

Phone Number

Facebook

Twitter/Other Social Sites

What Day Do Your Ads Break?

Day of the week

Which Departments Do You Have?

Please Check All That Apply. Please Check All That Apply. Liquor/Wines Pharmacy Deli/Bakery Butcher Floral Other

Other Departments:

What Local Brands or Products Do You Carry?

What Private Label Brands Do You Carry?

What Digital and/or Loyalty Brand Services Do You Offer?

Please Check All That Apply. Please Check All That Apply. Delivery Kiosk Online Ordering/Pick-Up Gas Rewards Website Coupons eCoupons Loyalty Program Other

Other Services:

Please List Any Local Charities, Non-Profit Organization or Local Events That You Support:

Are You Interested In Re-selling Ads or Air Space For Local Vendors or Businesses? Are You Interested In Re-selling Ads or Air Space For Local Vendors or Businesses? Yes No

Do You Have a Hispanic Customer Base? Do You Have a Hispanic Customer Base? Yes No

What Makes Your Store Unique? What Would You Like Your Community To Know?

How Did You Hear About Adergy?