Service Provided
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Gas
Food
Lodging
Location Information
Name on Logo: * (For example: Shell, McDonald's, Hampton Inn, etc.)
Store #:
PHYSICAL ADDRESS OF LOCATION: *
City: *
State: *
Zip Code: *
Phone: *
Website:
Interstate / Route: * (For example: I-10)
Exit / Crossroad Name: (For example: Main Street)
Exit / Interchange #:
Distance and Direction from End of Exit Ramp: (For example: 0.8 miles East)
County:
Billing Information
Company Name / Legal Entity: (If different from Location Name)
Billing Address:
City:
State:
Zip Code:
Contact Name:
Contact Email:
Contact Phone:
Contact Fax:
The facility has the appropriate state and local licensing
Generally describe your location / facility: (for example: water park or museum)
The facility is open year-round (if not please specify open season )
Open Season:
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day of
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June
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September
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November
December
through
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day of
January
February
March
April
May
June
July
August
September
October
November
December
Number of Parking Spaces Available
Estimated annual attendance
Free sanitary restroom facility for each sex with door lock, toilet that flushes, sink for washing, and tissue, sanitary towels or a drying device
The facility currently has other existing traffic control devices, such as supplemental guide signs (green or brown), or other signage provided by the state directing traffic specifically to or from your facility
Hours of Operation
Monday
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:
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15
30
45
am
pm
to
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:
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am
pm
Tuesday
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am
pm
to
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:
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am
pm
Wednesday
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pm
to
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pm
Thursday
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am
pm
to
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am
pm
Friday
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:
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to
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pm
Saturday
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to
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pm
Sunday
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:
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am
pm
to
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:
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45
am
pm
Other information you wish to provide:
Certification
I (Name of Applicant) *
Title of Applicant: *
of (Company Name/Legal Entity)