Missouri Interstate Logos - Application to Participate

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Application to Participate

Advertiser Information

Name on Logo: *

Store #:

Advertiser Address:

City: *

State: *

Zip Code: *

Phone: *

Website:

Is the location currently open for business?

Yes

Business Location Data

Interstate / Route: *

Exit / Crossroad Name:

Exit / Interchange #:

Distance and Direction from Exit: Example: 0.8 miles East of the Exit Ramp

County:

Billing Information

Business Type:

Corporately Owned

Individually Owned

Franchisee

Business Name / Owner:

Billing Address:

City:

State:

Zip Code:

Contact Name:

Contact Email:

Contact Phone:

Contact Fax:

Service Provided

Not all may be required for participation

Service:

Available at Location (check all that apply):

Unleaded Fuel

Diesel Fuel

Alternative Fuel / Specify Type

Oil

Tire repair service or information on available tire repair service in the area

Water for vehicle batteries and / or radiators

Compressed air for tire inflation

On premise attendant or cashier

Telephone available for public use

Free drinking water

Free cups for drinking water

Free sanitary restroom facility for each sex with door lock, toilet that flushes, sink for washing, and tissue, sanitary towels or a drying device

Hours of Operation

Monday :

to :

24 Hours

Tuesday :

to :

24 Hours

Wednesday :

to :

24 Hours

Thursday :

to :

24 Hours

Friday :

to :

24 Hours

Saturday :

to :

24 Hours

Sunday :

to :

24 Hours

Other information you wish to provide:

Certification

I (Name of Applicant) *

Title of Applicant: *

of (Company Name)

certify that the information I have provided is true and correct, and I will inform the program administrator of any changes to this information that may affect the availability of the service provided and our eligibility for participation. I further certify that we do not discriminate on the basis of color, religion, sex, nationality, or creed and we comply with the Americans with Disabilities Act as applicable to the service we provide. I understand that either the State Agency with oversight of this program or the program administrator may make inquiries or inspections to ensure that the minimum eligibility requirements for participation are being met.

Application Fee may apply and must be submitted before your application can be processed.
Please refer to the Participation Fees section for more information.

Submit