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Vendor Form

Company Name: ___________________________________________

Address: _________________________________________________
_________________________________________________
_________________________________________________

Contact Name: ____________________________________________


Email Address: ____________________________________________
Phone Number: ____________________________________________
Fax Number: ______________________________________________

Credit Card Information


Type: ____________________________________________________
Number: __________________________________________________
Expiration Date: ____________________________________________
CSC: _____________________________________________________
Authorized Signature: ________________________________________

Please fill out this form and fax back to skinnyCorp at (888) 595-3258 or
mail to skinnyCorp, 5225 N. Ravenswood Avenue, Suite 101, Chicago, IL 60640

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