Greater Houston Retailers Cooperative Association, Inc.

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11 Car Wash 12 Other Outside Services a Do you have a car wash? Yes No a Do you have an Air and Water Machine? Yes No If Yes, name of the car wash If Yes, Company's Name: i Do you Own it ? Yes No b Do you have a Vacuum Machine? Yes No ii Commission based Yes No If Yes, Company's Name: iii Is your car wash: c Do you Pressure wash your Parking lot? Yes No i Touchless If yes, How Often? ii With Brush Name the Company ? b Who is your chemical supplier for car wash? d Do you have an Ice Maker? Yes No Owned Lease c If No, Do you have plans to put car wash? e Do you buy ice bags? Yes No Yes No If Yes, supplier's Name: d Do you have rental space on your property? f Do you have a Drinking Water Vending Machine? Yes No Yes No Owned Leased If Yes, Leased from: 13 Coolers Walk-In Reach-In # Doors # Doors 14 Store Security a How many Soda Doors ? a Do you have a Vault safe? Yes No b How many Juices Doors ? If yes, how many Quantity c How many Gatorade Doors? Underground Floor Safe d How many Water Doors ? Time Delay Safe / TIDEL / TACCII e How many Energy Doors ? Regular Floor Safe f How many Dairy Doors ? b Do you have a Security Camera System? Yes No g How many Beer Doors ? If yes, how many ? Quantity h How many Wine Doors ? Indoor i Total # Cooler Doors Outdoor c How do you monitored camera system? DVR VCR Computer 15 Reach In Cooler Is it a Remote Recording ? Yes No a Quantity # Doors d Do you have a Bullet Proof Cabin ? Yes No 1 How many leased ? e Do you have an Alarm System? Yes No 2 How many owned ? If yes, Company's Name: b If Leased, Provide vendor's name 1 f Do have an armor truck to pick up your bank deposits? Yes No 2 If yes, Company's Name: c Paid FLM Coolers Quantity $ Amount 1 2 16 Deli 3 a Do you have a Deli? Yes No 4 Independent Franchise Name : Initial Here ________ Form: MA-BIS 104 Revised 05-26-2010 2 of 4
17 Computers 18 Freezers a Do you have a work computer at your store? Up-Right Coffins Yes No # Doors # Doors b Do you have Internet Service? Yes No a How many frozen food? If yes, name of the provider: b How many ice cream? Is it Dial Up? Yes No c Total Is it DSL/ Cable Modem? Yes No b Do you own or lease? 19 Insurance 20 Other Inside Store Services Do you have the following ? Do you offer any of the following services? a Workman Comp Insurance Yes No a Metro Bus Service tokens Yes No If yes, Provider: b Phone Card Yes No Expiration Date: If yes, Distributor's Name b Employment Accidential Ins. Yes No c Prepaid Cell Phone Yes No If yes, Provider: If yes, Company's Name Expiration Date: d Where do you buy register supplies from? c Tank Insurance Yes No e If yes, Provider: Do you have any of the following machines/equipments in your store ? (Please circle one that's applicable) Expiration Date: i Coffee Owned Leased d Property Insurance Yes No ii Cappuccino Owned Leased If yes, Provider: iii Fountain Machine Owned Leased Expiration Date: iv Royal Ice Owned Leased v Parrot Ice Owned Leased 21 License Permit # vi Hot Dog Owned Leased a Sales Tax vii Nacho Owned Leased b Tobacco Permit viii Popcorn Owned Leased c Lottery Permit ix Microwave Owned Leased d Lottery Retailer # x Ice Maker Owned Leased e Beer License xi Icy Machine Owned Leased f TECQ Facility ID xii Other Owned Leased Loaner Loaner Loaner Loaner Loaner Loaner Loaner Loaner Loaner Loaner Loaner Loaner 22 Financial Services a Do you offer any of the following financial services? iii Check Cashing Yes No i Money Order Yes No iv Do you use Check Cashing Software? Yes No If yes, Provider: If yes, Company Name: ii Money Transfer Yes No v Bill Payment Yes No If yes, Provider: If yes, Company Name: Initial Here ________ Form: MA-BIS 104 Revised 05-26-2010 3 of 4
Page 1 and 2: Page 1 Web Add: www.ghraonline.com
Page 3 and 4: STORE MANAGER ( This Person will no
Page 5 and 6: Member hereby agrees that all taxes
Page 7 and 8: CORPORATE RESOLUTION The Undersigne
Page 9 and 10: Greater Houston Retailers Cooperati
Page 11 and 12: Greater Houston Retailers Cooperati
Page 13: Greater Houston Retailers Cooperati
Page 17: GREATER HOUSTON RETAILERS CO-OPERAT

Greater Houston Retailers Cooperative Association, Inc.

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