Specialty Leasing Application

Licensee Contact Information

Contact Name Title*

First Name

Last Name

SS#*

Do not include dashes

Legal Entity Business Name*

Fed. Tax ID #*

Entity Type*

State of Formation*

Doing Business As*

Address*

Street Address

Address Line 2

City

State/Region/Province

Postal / Zip Code

Country

Business Phone*

Code

Number

Mobile Phone*

Code

Number

Email*

Website*

Proposed Business Information

RMU

Kiosk

In-line Space

Other

Length of agreement desired

Projected opening date*

Business description

What is the average price of the products you want to sell

What are your projected sales

Business Experience

Please describe the type of business*

What is or was the name of the retail business?

Date of Occupancy

What type of business*

RMU

Kiosk

In-line

What are were the average sales of your retail business

Please list the current or previous locations of your retail business

Please list the current and or previous locations of your retail business

Business References

Name Title*

Type of Business

Address