d

                 MEMBER APPLICATION

Application Requirement
•	Store Must be open for business
•	Original Application Package (Check list 1 to 7) completed and signed
•	All documents must be submitted with original application
•	Initial all pages

Application Package (15 Pages)

	

•	1.  Membership Application
•	2.  Membership Agreement 
•	3.  Corporate Resolution
•	4.  Requirements to be a Member Form
•	5.  Signage Program Form
•	6.  W-9 Form
•	7.  Business Information Sheet

Documents required- Copies

•	8.  Fee $100 (Business Check or Money Order payable to NTBA)
•	9. Authorized Representative’s Drivers License (Color Preferable)
•	10. Sales Tax Permit
•	11.  Articles of Incorporation/ Certificate of Formation- (Seal of The State of Texas)
•	12. Beer License (if not provided, can be submitted within 90 days)

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•	Only completed and accurate application with fees and all required documents will be accepted/processed
•	Must be submitted in Person or Registered Mail
•	No fax copies will be accepted
•	All documents, references and signatures are subject to verification through state agencies and/or other sources
•	Note: An Authorized Representative must be one of the owner of member company. More details between lines 11a and 12 Page 1 of  Membership Application

Important

For Office Use 
NTBA # Date:

	Office Phone: (	)	Mobile # (	)	

NORTH TEXAS BUSINESS ALLIANCE
                 111 Ferguson Court, Suite 100, Irving, TX 75062
MEMBERSHIP APPLICATION

Renewal Application

New Application

1.	Business Type:         	Gas Station / Convenience Store    	Other (specify): 	
2.	Member Name (Company Name): ___________________________________________________________________________
3.	DBA/Assumed Name: 
4.	Store Address:	City:
       State & Zip: ______________ County: _________________District:	Precinct:_______________________
5.	Mailing Address	City:_______________________________
       State & Zip:	--	County: 	District:	Precinct:
Store Phone: 
6.	Fax #: (	)	Home Phone:	E-mail Address: 	
7.	Was the store previously a member store of NTBA? YES / NO (Circle One)	If Yes, Previous NTBA #:	
8.	EIN (Fed ID #): 	Sales Tax ID #:	

Member Company Owners/Partners/Stockholders Information (Note: If Sole Prop. Or Partnership need SS# for each Partner):

	
9.	First Name_____________________	Middle Name____________	Last Name__________________________	Title                   Ownership-%
9a. (	) 	(	)	
Mobile Phone	Home Phone	Social Security Number	Driver License	State Issued
9.	
First Name	Middle Name	Last Name	Title	Ownership %
10a. (	) 	  (           )________________	________________________      ________________________       _____________
                  Mobile Phone	          Home Phone	Social Security Number	Driver License #	State Issued
10.	
                  First Name	Middle Name	Last Name	Title                                                                   Ownership %
11a. (	) 	 (       )_______________________	
Mobile Phone	Home Phone	Social Security Number	Driver License #	State Issued
>>>>>>>>>>>>>>> For Additional Name Use Separate Sheet <<<<<<<<<<<<<<<
Note: An “Authorized Representative” of a Member Company must be a natural person who is an owner of the Member Company
and who otherwise meets the guidelines, rule and regulations of NTBA 
Information of Authorized Representative of Member (Person responsible for making all business decisions including VOTING)
12.	Name of the Authorized Representative of Member – First:	Last: 	 Title:		
12a State Identification No./ Driver License No of Authorized Representative –State: ____ ID / DL (Circle One) No.	
Mobile No.:	Home Phone No.: 	

Information of M ember Store Manager (This Person is not eligible to VOTE)
13. First Name:	Last Name:	Title:
13a. Driver License No.:	State Issue:	Mobile No.:	
Please provide existing NTBA M embers (Company) References / Recommendation

14. Company Name:		Membership #:

14a. Authorized Representative Name	Signature: 	

15. Company Name:	Membership #:

*********************************************************************************************************

15a. Authorized Representative Name: _____________________________________________________________

FOR OFFICE USE ONLY

The undersigned authorized officer and authorized representative of above member hereby each represent and certify that (i) the above information is  true, correct and complete in all respects, (ii) the member and the undersigned hereby accept and agree to be strictly bound by and to strictly comply with  the Bylaws, Organizational Documents, Certificate of Formation as amended from time to time, Rules, Regulations, and Policies of North Texas Business Alliance (NTBA) and its directors and officers, as currently in effect and as amended or modified from time to time, (iii)  the undersigned individual listed as the member’s designated authorized representative shall be solely and exclusively authorized to act on behalf of the  member (until the designated authorized representative is properly changed in writing in accordance with NTBA guidelines and requirements) with  respect to all NTBA matters, including, but not limited to, exercising the member’s voting rights, and (iv) the undersigned individual listed as the  member’s designated authorized representative hereby accepts the designation of authorized representative and agrees to fully perform all obligations,  duties, and requirements required of him/her by NTBA in such capacity. 
16.	Signature of Authorized Officer:                           

16a. Printed Name of Authorized Officer – First Name:	Last Name:

18.	Signature of Designated Authorized Representative: 	Date:	
17a. Printed Name of Designated Authorized Representative - First Name:		Last Name:

Note: Acceptance of Membership Fee by NTBA does not automatically imply acceptance of Application. The collected fees will be returned if the application is not approved by the Board. Acceptance shall only occur upon written approval by the Board of Directors. Please sign this Membership Application and the attached Membership Agreement and return both with (1) Appropriate Membership Fees, (2) Copy of Federal Tax ID, (3) Copy of Texas Sales Tax Exempt Certificate, (4) Copy of Texas Tobacco Permit, and (5) Completed Membership Information Forms.

For Office Use Only

19.	Verified by -First Name:	 Last Name:	 Signature: 	Date:	
	Approved
	Rejected
20.	Approved by -First Name: 	Last Name:	Signature:	 Date: 	
(The “ Membership Effective Approval Date”)

21. Assigned Membership #: 	Membership Fees $:	Check #: 	

18. Received by -First Name:	Last Name: 	Signature:	Date: 	

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MEMBERSHIP AGREEMENT 
This Membership Agreement (“Agreement”) is made effective on the “Membership Effective Approval Date” (approval date indicated above in the Membership Application section of this Agreement) by and between Northern Texas Business Alliance,, a Texas cooperative association with its principal place of business located at 111 Ferguson Court, Suite 100, Irving, TX 75062 (“NTBA”), and the person or entity whose name is entered in above as “Member” in the Membership Application section of this Agreement as well as below at the end of this Agreement (“Member”). Both NTBA and Member are jointly referred to herein as “Parties” and individually as a “Party”.
Member acknowledges that NTBA has been organized for the benefit of its members as a Texas Cooperative Association pursuant to Title 6 of the Texas Business Organization Code. Therefore, in consideration of the membership offered and potential benefits to be derived there from, Member hereby agrees to abide by and be bound by the bylaws, organizational documents, Certificate of Formation as amended from time to time, policies, guidelines, rules and regulations of NTBA and its Officers and Directors, as the same are currently in effect and as amended or modified from time to time, and Member hereby also agrees as follows:
Member agrees to ratify and thereafter upon acceptance as a member of NTBA abide by the bylaws, organizational documents, Certificate of Formation as amended from time to time, policies, guidelines, rules and regulations of the NTBA and its Officers and Directors, as the same are currently in effect and as amended or modified from time to time. Member agrees and acknowledges that NTBA, through its Board of Directors and/or Officers, shall have the right to suspend or terminate Member’s membership for an indefinite period of time when such Member fails to act in accordance with or not in compliance with the terms and conditions of any NTBA bylaw, organizational document, Certificate of Formation as amended from time to time, policy, guideline, rule or regulation. Any of Member’s monetary benefits, funding (including, but not limited to, rebates/program/compliance), rights, or otherwise may be put on hold indefinitely or completely forfeited at the sole and absolute discretion of the Board of Directors. Any decision by the Board of Directors of NTBA will be final and binding and Member or any other person or party shall not contest such decision.
The individual listed on the above Membership Application form who is designated as the Authorized Representative of the Member will have the sole and exclusive right to exercise the voting rights of the Member as the authorized representative for the Member, which such voting power cannot be transferred. If the Member wishes to effect a change in the Authorized Representative, the Member hereby agrees to notify the NTBA office in a writing sent by United States certified mail, return receipt requested, at least thirty (30) days prior to such change in Authorized Representative taking effect. No such notice is effective against NTBA unless actually received and approved by NTBA. Upon such change a new completed application may be required for the approval of the Board of Directors of NTBA at the sole and absolute discretion of the Board.
The term of the Member’s membership shall be for up to a 1 year period upon payment of $100.00 in annual dues for each Member store and business location. Annual dues of $100.00 per Member store and business location is effective from January 1, 2007 and may be modified from time to time by the Board of Directors of NTBA. The membership period in NTBA is from January 1 to December 31 of each year. Unless Member notifies NTBA prior to the end of a calendar year that Member does not wish to be a member of NTBA in the following calendar year, Member’s dues for any succeeding calendar year will automatically be deducted from any patronage dividends, rebates, or other amounts due to Member in the period just prior to the new calendar year or, if such dues are not deducted from such dividends, rebates, or amounts, then Member shall pay dues for each year no later than the end of January of each such year.
NTBA may negotiate programs or agreements on behalf of its members. Member hereby agrees to take full responsibility and liability with respect to any and all programs, transactions, and agreements approved or negotiated by the Board of Directors of NTBA, including, but not limited to, fines, penalties and/or forfeiting any and all monetary or other benefits. Member fully assumes any and all of the risks involved in connection with any programs, transactions, contracts, and agreements approved, negotiated, or entered into by NTBA. Prior to participating in any NTBA deals, programs, transactions, contracts, or agreements, Member shall perform its own due diligence regarding such matters and shall not rely on NTBA or its Officers, Directors, Employees, or representatives for any reason or matter whatsoever. As part of Member’s due diligence, Member must itself ensure, at Member’s sole risk and cost, that Member is in full compliance with all laws, statutes, ordinances, rules, regulations, deed restrictions, zoning laws, community or other rules, contracts, leases (including with any landlord of Member), notes, agreements, and commitments of any kind prior to participating in any NTBA related program, transaction, deal, contract or agreement. NTBA and its Officers, Directors, Employees, and Representatives shall bear absolutely no responsibility or liability to Member or any other person or party whatsoever. Any program, transaction, deal, contract, or agreement shall be provided or presented to Member by NTBA on an “AS-IS”, “WHERE-IS” basis with absolutely no express or implied warranties of any kind or type. Member shall only enter into any transaction or deal at its sole option and risk and should also obtain any and all necessary consents, licenses, or permits of any governmental body or other person or party prior to entering into any transaction, deal, or agreement. NTBA shall not be responsible for providing any advice regarding or obtaining any consents, licenses, permits, or similar items of any kind. NTBA may, at its sole option and discretion, also sponsor different programs, such as a Victims Relief Fund, whereby each member will contribute such amounts as determined at the discretion of the Board of Directors of NTBA, which contributions shall be collected through a reduction in rebates or by direct contribution. Member participation in such programs may be mandatory, as determined by the Board of Directors of NTBA.
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Member hereby agrees that all taxes of any kind, including, but not limited to, State Sales Tax, Excise duty or levy, Federal Taxes (income or otherwise) and levy or any other Tax, Surcharges, Levy etc. are the sole responsibilities of the Member. Member agrees and covenants that if any Tax, Surcharge or Levy of any kind or type is enforced on NTBA on behalf of, against, or as a result of any agreement/contract signed on behalf of members or for the benefit of members, Member will immediately advance or reimburse NTBA all such taxes, surcharges, levies and/or other amounts.
Member authorizes NTBA to share with vendors, suppliers, and other parties determined by NTBA, Member’s business and other relevant information, both public and confidential, as deemed necessary at the sole discretion of the Board of Directors of NTBA, including, but not limited to, name of Member, name of the owners/partners of Member and/or Member’s business, address, phone number, EIN, State Tax Exempt number, State Tobacco Permit number, TABC Permit number, or any other information as deemed necessary to negotiate or comply with an agreement/contract or deal.
Any noncompliance by the Member of NTBA bylaws, organizational documents, Certificate of Formation as amended from time to time, rules, regulations, policies, membership agreements, applications, vendor or other contracts, agreements, vendor deals, or other requirements may lead to, among other things, Member’s membership being suspended or canceled at the sole and absolute discretion of the Board of Directors of NTBA. Upon suspension or cancelation of membership, any or all compliance funding, rebates, or other amounts may be deemed forfeited as determined at the sole and absolute discretion of the Board of Directors of NTBA.
NTBA and its past, present, and future Officers, Directors, employees, agents and representatives shall not be liable to the Member, the Member’s officers, directors, employees, shareholders, members, managers, affiliates, agents, or representatives, or to any other party whatsoever for (i) any injury or harm to person or damage to property or otherwise caused in connection with or that is otherwise directly or indirectly related to Member’s membership or participation in or with NTBA and/or NTBA’s programs, deals, contracts, seminars, or agreements, (ii) any loss, damage or injury that may be occasioned by or through the acts or omissions of any persons whatsoever, (iii) any loss or damage to any property occasioned by theft, fire, acts of God, public enemy, injunction, riot, insurrection, wars, court order, requisition or order of governmental authority, for any matter, (iv) any direct, indirect, incidental, consequential, punitive or special damages whatsoever (including without limitation, any damages claimed for loss of income, revenue, or profits or for loss of goodwill) arising from or related to Member’s membership or participation in or with NTBA and/or NTBA’s programs, deals, contracts, seminars, or agreements or the performance of this Agreement.
The Member agrees to indemnify and hold harmless NTBA and NTBA’s current, past, and future Officers, Directors, parents, affiliates, divisions, managers, members, shareholders, employees, contractors, agents, advisors, affiliates, representatives, attorneys, accountants, partners, successors and assignees and their respective partners, shareholders, officers, directors, managers, employees, invitees, or any other individual or entity otherwise connected, directly or indirectly, with NTBA (referred to collectively as the “Indemnified Party”) and each of them from and against any and all claims, causes of action, demands, suits, liabilities, losses, penalties, and/or actions asserted by any person or party, individually or through any representative, including all costs, attorney’s fees, settlement funds, damages or expenses resulting or allegedly resulting or arising, directly or indirectly, from this Agreement, the performance of this Agreement, any breach of this Agreement, and/or Member’s membership or participation in or with NTBA and/or NTBA’s programs, deals, contracts, seminars, or agreements, including, but not limited to, the act or omission of any third party vendor or any Indemnified Party, or any and all actual or alleged injuries or death of any person or damage to any property or otherwise due to or caused in connection with the performance of this Agreement or Member’s membership or participation in or with NTBA and/or NTBA’s programs, deals, contracts, seminars, or agreements, even if such indemnified liabilities are caused by the sole or contributory negligence or act of an Indemnified Party. The Member shall also indemnify and hold harmless NTBA and its Directors, Officers, employees, agents, affiliates, representatives, and contractors for the performance of their duties in the scope of their office for any reason or any cause of action whatsoever, from and against, among other things, any and all losses, liabilities, damages, penalties, etc, arising out of any or all vendors’ or suppliers’ agreements, contracts, programs signed or agreed by the Member (on Board’s recommendation) or the Board of Directors on behalf of the Members, and/or Member’s membership or participation in or with NTBA and/or NTBA’s programs, deals, contracts, seminars, or agreements.
Member understands and agrees that in some cases, deals, programs, agreements, or contracts, NTBA receives certain compensation, rebates, and/or other amounts against member store sales, volume, compliance and participation which helps pay, among other things, administration and other office expenses. NTBA reserves the right, at the sole and absolute discretion of the Board of Directors, to charge back Member (including deducting amounts from amounts due to Member) for lost revenue or other amounts if Member is not in compliance with any programs, deals, agreements, or contracts, including for those matters explained above.
A “Reportable Change” shall have occurred if (i) Member or any party sells, transfers, or conveys any of Member’s businesses or stores, (ii) Member or any party sells, transfers, or conveys substantially all the assets of any of Member’s businesses or stores, (iii) Member or any party sells, transfers, or conveys any ownership interest in Member, Member’s business, or any other current or successor entity operating the business, (iv) there is a change in the officer, director, manager, or member information for the Member and/or the Member’s business, or (v) there is any change or modification in the assumed name/dba name of Member and/or Member’s businesses. Member hereby agrees that no later than 30 days of any Reportable Change, Member shall notify NTBA in writing of such Reportable Change and all relevant details pertaining to such Reportable Change, including any and all
information later requested by NTBA. Member’s failure to timely report a “Reportable Change” or provide other information requested by NTTA shall be deemed a breach or non-compliance by Member, at the sole and absolute discretion of NTTA’s Board
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of Directors, and may result in, among other things, cancellation of Member’s membership, forfeiture of amounts owed, and/or penalties, charges, or other amount being charged to Member which the Board of Directors of NTBA shall be entitled to deduct from rebate payments or other amounts owed to Member.
Any notice provided to NTBA by Member must be in writing and sent to NTBA’s then principal office pursuant to United States postal mail, certified mail, return receipt requested, with postage prepaid. A written notice to NTBA shall not be effective until actually received by NTBA. Any notice provided to Member may be given by or through mail, telegram, facsimile, telephone, any NTBA or other publication or newsletter, electronic mail, the NTBA website, or verbally. If mailed, a notice to Member will be deemed delivered and received by Member when deposited in the mail addressed to Member (or his Authorized Representative) at his or her address as it appears in the records of NTBA. If given by telegram, a notice to Member is deemed delivered and received by Member when accepted by the telegraph company and addressed to Member (or his Authorized Representative) at his or her address as it appears on the records of NTBA. If given by facsimile, a notice to Member will be considered received when confirmation is received electronically. If given by telephone or verbally, such notice to Member will be deemed received by Member when communicated orally. If given by electronic mail or posting on NTBA website, a notice to Member is deemed received by Member when the electronic mail is sent to Member (or Member’s Authorized Representative) or when posted on NTTA’s website.
This Agreement shall be governed by, construed under, and enforced in accordance with the internal laws of the state of Texas, without reference to conflicts of laws. Member consents to jurisdiction and venue in the state and federal courts of Harris County, Texas. The transmission of an executed copy of this Agreement, or any document referenced in this Agreement, or the signature page(s) hereof or thereof, by facsimile or telecopy shall be treated in all manner and respects as the delivery of an original counterpart of this Agreement or such document bearing the original signature(s) of the party (ies) utilizing any such transmission device. This Agreement constitutes the final and entire Agreement and understanding between NTBA and the Member relating to the subject matter of this Agreement and supersedes all prior understandings and agreements (whether written or oral) between the parties concerning the subject matter of this Agreement. No partnership, joint venture, trust, franchise, employment or other similar relationship is created between the parties in connection with this Agreement. Moreover, no agency or other similar relationship is created between the parties in connection with this Agreement. Member shall not have any authority or represent that it has any authority, to bind NTBA in any manner whatsoever. Member may not assign or transfer its membership in NTBA and/or its rights or obligations hereunder. Any attempted transfer or assignment by the Member shall be null and void. This Agreement shall not confer any rights upon any person other than NTBA and NTBA’s affiliates, successors and assigns. Any disputes must be settled in good faith between NTBA and Member. If dispute resolution is not achieved as above, either party may take the dispute to the next level which is deemed as seeking Arbitration or Mediation from the Aga Khan Conciliation and Arbitration Board for the Southwest United States. However, the decision from the Aga Khan Conciliation and Arbitration Board for the Southwest United States is not binding on the parties.
MEMBER NAME (Company Name)	(Name of Member Entity or Member
Individual if Proprietorship)
By:	(Signature of Authorized Officer or Equivalent)

Authorized Officer’ Full Name:	
Date:
By:	(Signature of Authorized Representative)

Authorized Representative’ Full Name:	
Date:

CORPORATE RESOLUTION
The Undersigned Corporate Secretary of	, a
Corporation/Limited Liability Company/Limited Partnership duly organized and existing under the laws of the state of Texas, hereby certifies that a meeting of the Board of Directors (or equivalent governing body for a non- corporation entity) of said entity was duly called and held at
	, in the City of 	, in the County	of
	, Texas on	. The undersigned further certifies that
a quorum for such meeting was present and that the following resolutions were fully and
unconditionally adopted	and	have been duly entered	into the regular	minute book	of
	 in accordance with the by-laws (or equivalent governing
document), now in full force and effect to with:
RESOLVED, That the	President and	the Chief Operating Officer of	the
Corporation, 	, is hereby authorized to acquire and maintain a
membership in the NORTH TEXAS BUSINESS ALLIANCE, (NTBA) and to pay all fees, dues and other amounts and execute any and all documents, agreements, and the instruments that are required by NTBA and that are otherwise required to perfect such membership.
IN WITNESS WHEREOF I hereunto set my hand as Secretary of the said Corporation/Limited Liability Company/Limited Partnership on this _____ day of	, 2010
Signature of Secretary: ______________________
Printed Name of Secretary:
______________________

North Texas Business Alliance
111 Ferguson Court, Suite 100, Irving, TX 75062
Office: 972-242-0100 / Fax: 972-242-0075
Requirements to be a member

Submit complete NTBA Application with all required documents, subject to approval Pay $100 Annual Membership Fees
Participate and comply with all mandatory deals, NTBA approved special promotions, guidelines and policies
Display NTBA Logo at the front door
Follow current ‘PLANOGRAM’
Display Out Door Sign in compliance with NTBA guidelines
In-Store Membership Orientation to be attended by Authorized Representative
Benefits to NTBA Members
Members will receive discounts on their eligible purchases
Will get one free Out Door Signage system with installation (Value $700) Regular rebates
Any additional incentives / bonuses received from vendors
Process of Non-Compliance
If a member representative does not abide by the above mentioned policies, he / she will be considered in Non-Compliance. After hearing from all concern parties, NTBA Compliance Committee with the approval of the Board of Directors will apply following penalties.
Penalties and Suspension

	First Offense: No rebate will be given for that particular quarter or $300 whichever is higher Second Offense: No rebate will be given for that particular quarter or $600 whichever is higher. Third Offense: No rebates for that quarter and will be terminated from NTBA membership	

This is to acknowledge that I have read the above rules and regulations and have agreed to accept it and abide by the above rules and regulations.
Store Name:	Cell Phone:	
Authorized Representative Full Name (Print)	
Authorized Representative’s Signature:	Date:

North Texas Business Alliance
111 Ferguson Court, Suite 100, Irving, TX 75062
Phone: 281-295-5300 / Fax: 281 -295-5399
NTBA Signage Program 
•	NTBA is proud to introduce an outdoor signage program for its Premium member stores.
•	NTBA will make available for its Premium member stores a complete sign structure to be installed on the outside of the store above the main entrance of the store.
•	This sign system will consist of a permanent structure with a changeable message or insert, which will be available in two (2) sizes as follows (a) 11/2 feet high by 15 feet (b) 11/2 feet high by 20 feet.
•	The purpose of this program is to provide extra tool to our Premium member store to stay competitive and advertise NTBA specials and promotions. The signage structure for the member stores will be for the exclusive use of NTBA approved inserts only.
•	All signage structure, installation of the structure and all inserts will be provided to member by NTBA free of charge, if a member executes the signage agreement with NTBA. However, if a member defaults in its performance of obligation under the agreement than the defaulting member may be charged with the cost of $700 for the signage program.
•	Multiple store owners, please note that each member store will be required to execute a separate agreement.
•	Each member will be required to maintain sign structure in good condition all the time and participate fully in the promotions and install inserts on a timely manner so that it does not adversely affect the remaining members and does not harm the success of this program.
•	Your complete and enthusiastic support of this program is extremely vital for its success. This will provide a much-needed encouragement to the Board of Directors to bring bolder program for the benefit of its Premium members in the future.
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	For Office Use NTBA #	

North Texas Business Alliance
111 Ferguson Court, Suite 100, Irving, TX 75062
Phone: 972-242-0100 / Fax: 281 -295-5399
Agreement Regarding Participation in Outdoor Signage Program 
The undersigned Premium member of the NTBA has agreed to participate in the NTBA Outdoor Signage Program and the Member agrees as follows:
1.	To install all signs provided by the NTBA or its vendor for the promotional advertising at the designated location on the premises. All signage in the program shall remain at the designated location until further notice from the NTBA or the authorized vendor.
2.	All outdoor sign inserts shall remain installed for duration of 1 month or term of promotion whichever is less unless noted otherwise.
3.	All signage installed shall only be for the NTBA approved program and member shall ensure that all signs are in compliance with all city, county, and/or other regulations and any requirements of the Members lease agreements, if any.
4.	All signs and inserts will be supplied at the sole cost and expense of the NTBA. In the event the member fails to comply with all the proper requirements, the NTBA may assess the member all costs related to the sign and deduct the amount from any NTBA disbursements owed to such Member.
5.	Member agrees to maintain the sign in good condition at its expense. Member agrees to change and/or install new inserts as and when needed by NTBA.
6.	Member agrees to attend at least two (2) NTBA town hall meetings each year.
7.	 The undersigned member agrees that NTBA shall not be responsible for any problems, complaints, demands, liabilities, and expenses related to participation in the program or any failures of the vendors to perform their obligations to the NTBA or to the individual member stores. The member hereby releases NTBA from any liability arising out of or relating to members’ participation in the program.

Frame Size:	Select one	15 ft by 1.5 ft (small)
  20 ft by 1.5 ft (big)

I have permission from landlord or authority to install / display NTBA spanner frame I do not have permission from landlord or authority to install NTBA spanner frame Ihave a spanner board already from previous owner in good condition.

Store Name:	Store Phone	
Authorized Representative’s Name (Print):	
Authorized Representative’s Signature:	Date:	

-9

Form W
(Rev. October 2007)
Department of the Treasury Internal Revenue Service

Request for Taxpayer
Identification Number and Certification

Give form to the requester. Do not send to the IRS.

Name (as shown on your income tax return)
Business name, if different from above

Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership) © Other (see instructions) ©

Corporation	Partnership

Check appropriate box:

Individual/Sole proprietor

	Exempt payee	

Requester’s name and address (optional)

Address (number, street, and apt. or suite no.)
City, state, and ZIP code
List account number(s) here (optional)
Part I	Taxpayer Identification Number (TIN)

Social security number

or

Employer identification number

Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter.

Certification

Part II
Under penalties of perjury, I certify that:

1.	The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2.	I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (defined below).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must provide your correct TIN. See the instructions on page 4.

Sign Here

Signature of
U.S. person	Date ©

General Instructions
Section references are to the Internal Revenue Code unless otherwise noted.
Purpose of Form
A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA.
Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to:
1.	Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),
2.	Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners’ share of effectively connected income.
Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9.
Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are:
●	An individual who is a U.S. citizen or U.S. resident alien,
●	A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States,
●	An estate (other than a foreign estate), or
●	A domestic trust (as defined in Regulations section 301.7701-7).
Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners’ share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income.
The person who gives Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States is in the following cases:
●	The U.S. owner of a disregarded entity and not the entity,

ii
iii
iv
v vi

i

 Yes  No

Provide company name:

Other:___________________________________

Unleaded         Plus        Super         Diesel            Propane

If yes, Product Type (circle all that apply)		

e      What kind of POS/Console do you have? (circle applicable)

a	Do you sell Gasoline?	Yes	No

Gasoline

b     Number of pickups (Weekly):

a

d         Do your employees wear a name badge?

i	           Est. Neighborhood %

ii	           Est. Freeway %

iii	           Est. Commercial %

iv        Est. Road %

  Your store business is mainly from

BUSINESS PROPERTY

a. Store Size      Square Feet:________________

10

1 Store Name:	Company Name:
2 Store Address:	City	State	TX	Zip
3 Store Ph#: 	Cell phone #

4

A       Do you have a spanner board?	Yes  /   No

9

        a        Do you have a payphone?	Yes	No

a	Dumpster size: (In Yards)

d Monthly Charges:

5

7

8

b	Is your store open 24 hours?	Yes	No

c          Do you have uniform for employees ?	Yes	No

c	Service Provider:

Store Type

i

ii

iii

Your Contract expires on:

Owned

If No, Store timing:

If yes, what size?

If yes, how many ?

If yes, Provider Name:

C-Store	Supermarket	Liquor	Tobacco	Newsstand

3 Inserter	4 Inserter

Store Environment

Spanner Board

Pay Phone

Dumpster

North Texas Business Alliance
111 Ferguson Court, Suite 100, Irving, TX 75062

Leased

Yes	No

%

%

%

%

Business Information Sheet

f	Who does your SIR?
g	How do you monitor your tanks?

6

c	Who is your Jobber?

d	Gasoline Equipments

b

h	Who maintains and repairs the pumps?

Gasoline Brand (Please circle one that's applicable):

i

ii	Manual Stick	Yes	No

Automatic Gauging	Yes	No

Chevron

Citgo

Conoco

BP

Mobil	Other Generic Brand:

Do you own gasoline equipments?	Yes	No

Number of MPD / Pumps

Number of Tanks

Number of Noozle

Do pumps have card reader

Exxon

Hess

Is it commission based Gasoline ?

Gilbarco

Owner	Jobber

Passport

Valero

Texaco

Shell

Phillips 66

RaceWay

Unbranded

Other:

Ruby	Nucleus

Other:

Yes	No

Initial Here_______________

Initial Here____________

c        Paid FLM Coolers
1
2

b          If Leased, Provide vendor's name

A  How many Soda Doors?

Car Wash

12

11

Yes	No

No

i

Do you Own it ?

Yes	No

No

Commission based

ii

Yes	No

iii

Is your car wash:

No

i	Touchless

ii	With Brush

b

Owned

Lease

Yes	No

No

Yes	No

Owned

Leased

Coolers

13

Store Security

14

Yes	No

If yes, how many

b

Quantity

c

d

e

Yes	No

Quantity

Indoor

Total # Cooler Doors

i

Outdoor

Reach In Cooler

15

Yes	No

Quantity

# Doors

a

2

1

2

$ Amount

Quantity

Deli

16

3

4

a Do you have a car wash?

 d    Do you have rental space on your property?

g    How many Beer Doors?

c    If No, Do you have plans to put car wash?

h   How many Wine Doors?

f     How many Dairy Doors?

Who is your chemical supplier for car wash?

If Yes, name of the car wash

How many Juices Doors?

How many Gatorade Doors?

How many Water Doors?

How many Energy Doors?

1 How many leased ?

How many owned ?

Walk-In # Doors

Reach-In # Doors

f	Do you have a Drinking Water Vending Machine?	Yes

f	Do have an armor truck to pick up your bank deposits?                          Yes     No

a	Do you have an Air and Water Machine?	Yes

c	Do you Pressure wash your Parking lot?	Yes

d       Do you have an Ice Maker?	Yes	No

e       Do you buy ice bags?	Yes	No

a	Do you have a Vault safe?

c	How do you monitored camera system?

d	Do you have a Bullet Proof Cabin ?	Yes	No

e       Do you have an Alarm System?	Yes	No

a	Do you have a Deli?	Yes	No

b      Do you have a Vacuum Machine?	Yes

b	Do you have a Security Camera System?

Name the Company ?

If Yes, Company's Name:

If Yes, Company's Name:

If yes, How Often?

If Yes, supplier's Name:

If Yes, Leased from:

If yes, how many ?

Is it a Remote Recording ?

If yes, Company's Name:

If yes, Company's Name:

Independent	Franchise Name :

Time Delay Safe / TIDEL / TACCII

Underground Floor Safe

Regular Floor Safe

Other Outside Services

DVR VCR Computer

a    Sales Tax

b    Tobacco Permit

c    Lottery Permit

d     Lottery Retailer #

e     Beer License

f      TECQ Facility ID

Computers
17	18

21

22

19

a     Do you have a work computer at your store?
Yes	No
b     Do you have Internet Service?	Yes	No

A             Workman Comp Insurance

d Tank Insurance

a	Do you offer any of the following financial services?	iii

b	Employment Accidential  Ins.

c    Property Insurance

i

ii

Do you have the following?

Expiration Date:

Expiration Date:

If yes, Provider: Expiration Date:

Expiration Date:

Money Order	Yes	No	iv

Money Transfer	Yes	No	v

If yes, name of the provider:

Is it Dial Up?	Yes	No

Is it DSL/ Cable Modem?	Yes	No

If yes, Provider:

If yes, Provider:

If yes, Provider:

License

If yes, Provider:

If yes, Provider:

Insurance

Yes	No

Yes	No

Yes	No

Yes	No

Permit #

Financial Services

a     How many Ice Cream?

c	Total number of Freezers

20

a	Metro Bus Service tokens	Yes	No

c	Prepaid Cell Phone	Yes	No

d	Where do you buy register supplies from?

e	Do you have any of the following machines/equipments in your store ?

b     How many frozen food?

b	Do you own or lease freezer?

b	Phone Card	Yes	No

x

xi

xii

v

vi

vii

viii

(Please circle one that's applicable)

Do you offer any of the following services?

i

ii

iii

iv

ix

Coffee	Owned

Cappuccino	Owned

Other	Owned

Check Cashing	Yes	No

Parrot Ice	Owned

Nacho	Owned

Popcorn	Owned

Microwave	Owned

Do you use Check Cashing Software?	Yes	No

Bill Payment	Yes	No

Fountain Machine	Owned

Royal Ice	Owned

Hot Dog	Owned

Ice Maker	Owned

Icy Machine	Owned

If yes, Distributor's Name

If yes, Company's Name

If yes, Company Name:

If yes, Company Name:

Other Inside Store Services

Freezers

Leased

Leased

Leased

Leased

Leased

Leased

Leased

Leased

Leased

Leased

Leased

Leased

Up-Right

# Doors

Loaner

Loaner

Loaner

Loaner

Loaner

Loaner

Loaner

Loaner

Loaner

Loaner

Loaner

Loaner

# Doors

Coffins

Initial Here

	Please check the box for the vendors currently serving the Store	
23	Vendors	√	Account #	Expiration Date		Vendors	√	Accout #	Expiration
Date	
a	Affordable Power			ae	Printed Ice Bags				
b	Arrest a pest			af	ProActive Services				
c	ATM Link			ag	Quality Nozzle Company				
d	Barcel USA (Bimbo Group)			h	Red Bull				
e	Baxter Environmental Inc.			ai	Republic Waste Service				
f	Blue Bell			aj	Royal Ice				
g	Borden			ak	Sweet Cravings, Inc				
h	Cintas Corporation			al	Texas Jasmine				
i	Coca-Cola Bottling Group			am	Universal Merchant Processing				
j	Community Coffee			an	Waste Management				
k	Deli Express			ao	Yumi Ice-Cream				
l	Dr. Pepper Bottling Group			Ap				
m	Frito Lay			aq				
n	Gatorade			ar				
o	Geo Environmental			as				
p	Global Coffee Company			at				
q	Grocery Supply Company			au				
r	Heritage Propane Express			av				
s	Huntsville Wholesale			aw				
t	In-Time Distributors Inc			ax				
u	Lance			ay				
v	Maxtell Communications			az				
w	Moms			ba				
x	Monotronics			bb				
y	Monster			bc				
z	Oak Farms			bd				
aa	Ozarka			be				
ab	P & L Maintenance			bf				
ac	Pepsi Bottling			bg				
ad	Prasla Insurance			                                         bh                            				
	You may list any additional vendors if any	

Revised 01/13/11

                                                                                                                                                                                                                               Initial Here___________