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Wilton Manors Business Association
Listing Information

BUSINESS NAME: _________________________________________________________________

CONTACT (to be printed in directory): ___________________________________________________

ADDRESS: ________________________________________________________________________

CITY: ____________________________________________________________________________

ZIP: _____________________________________________________________________________

PHONE (note area code must be included): _____________________

FAX NUMBER (not for publication): __________________________

E-MAIL: ___________________________________________

WEB SITE: _____________________________________

LISTING CATEGORY:_____________________________________________________________

BUSINESS DESCRIPTION: _________________________________________________________

I AM A: ________NEW MEMBER ________RENEWING MEMBER

MEMBER SIGNATURE:_____________________________________________________________________

DATE PAID BY: ____________________CASH___________CHECK #________________