In-Store Vending Information Sheet

Submit the completed form below and mail the required documentation to initiate an In-Store Vending request.

Name:

City:

State:

Zip:

Legal Business Name: (Legal name of Company that would appear on a lease)

D/B/A: (Name that would appear on the lease )

Contact/Owner:

Mailing Address:

E-mail:

Phone:

Fax:

Basic Concepts/Service/Menu:

Target Customer:

Average Sale:

Current Business Locations:

Min/Max Square Footage:

# of Units Open:

# of Years:

If leasing inside Wal‐Mart Stores, Inc., will other units remain open? Yes No

Dun & Bradstreet Number:

Store Number(s) interested in:

Annual estimated Profit per sq foot:$

Estimated Monthly Energy Usage Cost:$

Suggested Walmart commission rate (%):

Suggested/Anticipated Income per Month:

Placement Location Requested (vestibule, front wall, sidewalk, etc):

Requested Format (SC, NMkt, EXPRESS, Div01---or Large or Small format stores):

Please attach the following documents in an e-mail addressed to otherinc@wal-mart.com:

2 Years Audited Financials/Income Tax Returns
Local/National Organization Membership
Business Proposal Including Performance Modeling

Nothing in this letter constitutes an offer to lease space, nor does this letter constitute an acceptance by Walmart Stores US, or any of its affiliates of any offer to lease. This letter is not a lease or agreement; it is merely notification of available space for which you may be able to negotiate a lease with Walmart or one of its affiliates. If the parties enter into a lease agreement, only the terms and conditions of that agreement will govern the lease.