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2. Business Name*
4. Address1*
6. Address2
8. City
9. State
10. Zip
12. Telephone*
14. Website
16. Facebook URL
18. Twitter URL
20. Hours of Operation*
    M, T ,W, Th, F, Sat, Sun
22. Select Category*

    1. Restaurants and Nightlife
    2. Retail
    3. Lodging
    4. Banquet Facility
    5. Commercial Service
    6. Salon Services
    7. Attraction
    8. Property
    9. Other
24. If other, what? (From above)
26. Business Owner: First Name
27. Last Name
29. Business Owner Phone
31. Main Business Contact Person: First Name
32. Last Name
34. Main Contact Phone
36. Email Address
38. Building Owner: First Name
39. Last Name
41. Building Owner Phone
43. Number of Full-Time Employees
    -- Select One --12345-2526-5051+
44. Number of Part-Time Employees
    -- Select One --12345-2525-5051+
46. Do you consider your business to be part of a defined "Business District?"*
    -- Select One --YesNo
47. Business District Location*
    -- Select One --Moline Centre/DowntownOlde TowneUptownRiversideJohn Deere RoadOther
49. If other, where? (see above)
51. Date/Year Business Opened
53. Description
    Please write a brief description (up to 50 words) of your business as you would like for it to appear on the website. Moline Main Street reserves the right to edit this information, but any changes will be submitted to you for your final approval.
55. Photo
    Please submit an electronic photo, preferably an outside view or impact photo, of your business..
57. Logo
    Please submit a digital version of your logo preferably in a JPEG or TIF file format.
Leave This Blank:


59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit

* indicates a required field