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Company Name:
Address Line 1
Address Line 2
City State Zip
First Name Last Name
Phone (Day) Evening
Fax Number Email

Temp. Street Fair Vendor Permit # Exp. Date
Name on certificate
Address On Certificate
Certificate of Authority #

Do you own a store? Do you sell food?
Product List Please enter a list of products your company sells.
630 9th Avenue, Suite 417, NY, NY 10036 • phone (646) 230-0489 • fax (646) 230-0718