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Order Form

  Dealership Number * 

            First Name *

            Last Name *

                    Title *

    Contact Phone# *  Ext:

      Contact Email

*Required Fields

You will be contacted within 24 hours by our customer service representative.  They will ask you the questions below and confirm the type of vending that you currently have and the brands that you would like on your vending machines.  They will also answer any questions you may have about the vending program.


Information About Your Dealership


Completion of this questionnaire is optional.  By completing it you will expedite our customer service response call. This will enable us to tailor our response and be respectful of your time.

Number of Employees     Number of Service Tickets/Day

Brand(s) of Equipment Needed:     
Chrysler
| Dodge| Jeep  | Dodge Motorsports      
 

Current Types Of Vending

Cold Beverage
    

       Can Soda Machines 
   Vend Price   

     Bottle Soda   Vend Price       

       Do you receive any commission now? Yes  No     

                       Commission %

Do you have a contract with your vendor? Yes  No   

   Current Vendor Name

Current Vendor Phone#


Snack               

 Snack Machines    Vend Prices Candy  

                                                               Chips              

                                                              Pastry      

        Do you receive any commission now? Yes  No       

                       Commission %

Do you have a contract with your vendor? Yes  No   

   Current Vendor Name

Current Vendor Phone#


Coffee    

Vend Price         Yes  No

       Do you receive any commission now? Yes  No     

                       Commission %

Do you have a contract with your vendor? Yes  No   

   Current Vendor Name

Current Vendor Phone#


Cold/Frozen Food               
Yes  No

        Do you receive any commission now? Yes  No     

                       Commission %

Do you have a contract with your vendor? Yes  No     

 Current Vendor Name

Current Vendor Phone#

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