Company Name:

For Sole Proprietors, please enter your legal name and if different Name Doing Business As(DBA):

Key Contact Name and Title:

Address:

Remitance Address:

City:

State:

Zip:

Phone:

Fax:

Cell/Alternative Number:

Email:

Website URL:

Years In Business:

Tax ID #:

Brief Summary of products/services(please keep it short and simple):

How my product/service will add to the value to Vallarta Supermarkets delivers to it's customers(please keep it short and simple):

Please list current and previous sales outlets for your product(please keep it short and simple):

IF APPLICABLE: Will your company provide demos?:

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