Dealer Information Form

Name:

Entity Name:

Address:

City:

State:

ZIP:

Phone:

Type:

Home

Cell

Work

Email:

Are you currently, or have you been, a fuels retailer?:

Yes

If yes, please explain:

Do you own or have leasehold interest in retail property where you would potentially like to market the Shell Brand?:

Yes

If yes, give a brief description of the location.:

Please provide any additional questions or comments you may have:

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