114 N. Lafayette St.
 Greenville Michigan 48838   
 Phone 616-754-8888 / Fax 616-754-5281      
 www.greenvillebusinessnetwork.com

                                                        
                                         Date Submitted: _____________

                                         Date Approved: ______________

 BUSINESS NAME: _____________________________________

 ADDRESS: ___________________________________________

 PHONE: (WORK) ________________   (HOME) _____________

 EMAIL ADDRESS: _____________________________________

 CONTACT PERSON: ___________________________________

 POSITION: __________________________________________ 

 BUSINESS TYPE: _____________________________________ 
 ADDITIONAL BUSINESS LOCATIONS: _____________________

 ____________________________________________________

 YEARS IN BUSINESS: __________________________________

 REFERRED BY:    ______________________________________
 

 REFERRALS:

1. Name: ____________________________________________ 
    Business: __________________________________________

    Phone: ____________________________________________

2. Name: ____________________________________________
    Business: __________________________________________

    Phone: ____________________________________________

3. Name: _____________________________________________

    Business: __________________________________________

    Phone: ____________________________________________