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Application for Participation (Due by January 6, 2012)

Instructions: Please provide the following information in the space provided. Remember to sign and date this sheet at the bottom. Your interest in participating in the Challenge, and the information provided on this sheet, will remain confidential within the Pensacola Business Challenge staff and judging panel. Mail this application by January 6, 2012 with a check or money order for $40 to: Pensacola Business Challenge | P.O. Box 2096 | Pensacola, FL 32502-2096 Name of Individual(s): _____________________________________________________ Address/City/Zip: Telephone: ______________________________________________________ ________________________ Fax: _______________________ _____________________________________________________ ____________________________________

Email address:

Are you currently employed? (Yes / No) Name/Type of Proposed Business: New or Existing Business?:

________________________________________

________If Existing, Expansion or Relocation?:_________

Briefly Describe Your Reason for Participating in The Challenge: ____________________ ________________________________________________________________________ ________________________________________________________________________ I hereby certify that the statements set forth above are true and accurate as of the date of the application.

By (signature): ___________________________________ Date: ____________ Print Name: _____________________________________

Pensacola Business Challenge P.O. Box 2096 Pensacola, FL 32502-2096 www.PensacolaBusinessChallenge.com

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