This Form is for Businesses Only
CLICK HERE for the Chepachet.com Non-Profits Application Form

 Instructions

1. Complete the form below, filling in any information that applies to your business AND that you want published on the internet. Most info is optional.
2. Click on the "Submit" button at the bottom of this page to send your application to Chepachet.com.
3. After being transported to the payment page, complete the transaction by clicking on the "PayPal" payment button.

Your Name REQUIRED
Your Email REQUIRED
Business Name
Slogan or Motto
Owner/Contact Person
Street Address
Mailing Address
Town
State
Zip
Contact Phone
Toll Free
Fax
Pager
Cellular
Voice Mail
E-Mail
Web Site Address
Hours
Credit Cards Accepted
Memberships/Affiliations
Directions to Location
Handicapped Facilities	Check all that apply:  Ramps  Parking  Restrooms  Other (list below)
Description/Profile Describe your company briefly, using a maximum of 200 words. We have a Web Site Search Feature, so be sure to include key words that your customers might be looking for (Ex: collectibles, Beabie Babies, bears, etc). Writer's block? See one of our listings for ideas or jot down a few phrases and we'll compose it for you!
Logo or Photo You are allowed one logo, photo, etc. for your Chepachet.com page. You may send the image electronically as a .jpg or .gif file, or you may mail good quality art work to be scanned by us.  I will e-mail the logo/photo  I will mail the logo/photo  Please return my logo/photo
Special Offer A coupon will help to bring customers from your Chepachet.com storefront to your actual place of business. If you like, list a special offer or "Print & Clip" coupon for your online customers. Ex: One free widget with this coupon (limit one per customer)
I hereby authorize publication of the information contained herein on Chepachet.com.