Name of Business:

Contact Name:

Address:

City:

State:

Zip:

Phone:

Email:

Website:

Location Markers (i.e. Downtown Lima, Next to mall, etc.):
Products Sold or Services Offered:

In the space provided, please describe your business:

Is this a Special Offer or Sale Promotion?

Date(s) Offer or Sale Valid:

Anything else you would like to mention?