Enter information as completely as possible. Please click the "SUBMIT" button at the bottom of this form after reviewing all provided information. (* denotes required field)

Business Name:*
Business Address:*
Business Address 2:*	(include unit/suite #)
City:*
State:*	-select- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY   Zip:*
Contact Person - First name:*
Contact Person - Last name:*
Contact Person Email:*
Business Phone:*	Ext.
Business Fax:*
Total number of participating business locations:*

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General Information:
Have you filed bankruptcy in the last 5 years?	Yes   No
Are you a convicted Felon? (Sorry for having to ask that one!)	Yes   No
Credit Rating:
Production area sq. ft:
Office/customer area sq. ft:
Shop sq. ft:

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Business Information:
Would you be considered an independently owned business?*	Yes   No
Annual gross sales:*
# of Employees:*
Years in Business:*
Average repair order ($ Amount):*
Primary paint brand:*	- SELECT ONE - AKZO Nobel - Lesenol AKZO Nobel - Sikkens BASF - 90 Line BASF - Glaso BASF - Glasurit BASF - Limco BASF - Onyx BASF - RM Dupont - Centari Dupont - Chroma Base Dupont - Chroma Clear Dupont - Chroma Premier Dupont - Chromax Pro Dupont - Nason Dupont - Permahyd Dupont - Spies Hecker Dupont - Standohyd Dupont - Standox PPG - DBC PPG - Delstar PPG - Deltron PPG - Envirobase PPG - Global Line PPG - Nexa PPG - Omni Sherwin Williams - 2k Sherwin Williams - Acrylyd Sherwin Williams - Ultra
Primary rental car company:*	- SELECT ONE - Enterprise Hertz Avis Budget Alamo Dollar Thrifty National Other

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Acknowledgement:

	I agree to keep all Assured Performance Co-Op Terms and agreements confidential.
	I will not use any rates that Assured Performance Cooperative has secured in my own negotiations with other vendors or share them with any other groups. Violation constitutes immediate grounds for termination of Membership and forfeiture of any rebate-rewards accumulated.
	I acknowledge that all rebate-rewards will be received and processed through the Assured Performance Co-Op and that I will only receive my reward-rebates as long as I pay my bills to the dealer/vendor in question according to my credit terms or net 10 and maintain a return rate below 10%.
	I understand that a small administrative fee (up to 25% of reward rebates) will be deducted from my rewards earnings.
	My rewards may be applied toward the purchase of Assured Performance marketing tools or disbursed upon my written request upon the anniversary of my enrollment.
	Rewards disbursement is contingent upon ongoing membership in the buying group.
	Program participants, details and terms may change at any time without notice.

Electronic Signature

Date:	Sep 8, 2010
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