Name *

First Name

Last Name

Telephone *

(###)

###

####

Is your organization wheelchair accessible? *

Yes

No

Do you offer patrons and customers free WiFi? *

Yes

No

Student Discount Offer (Please check one) *

15% off

20% off

25% off

30% off

Other

Start Date of the Agreement *

MM

DD

YYYY

Date *

MM

DD

YYYY

Terms and Conditions *

I have read and agree to the following terms and conditions