Intake Form for the "Molokai Go Local! Business Directory"

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* 1. What is your business name?

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* 2. Business description:

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* 3. Phone number(s):

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* 4. Business Email:

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* 5. Does your business have a website? If so, what is it?

Yes

No

website address:

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* 6. Who is the Owner(s)?

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* 7. Contact person (if someone other than owner):

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* 8. Physical address:

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* 9. Mailing address:

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* 10. Category (such as restaurant, farm, auto repair, lodging, clothing, artists, consultants, etc.):