Membership Audit

PLEASE COMPLETE ALL APPROPRIATE FIELDS TO UPDATE YOUR MEMBER PROFILE
FOR MORE THAN 5 STORE LOCATIONS, PLEASE DUPLICATE THIS FORM AND COMPLETE.
YOU MAY ALSO PROVIDE AN EXCEL SPREADSHEET OF STORE/LOCATION DETAILS.

Membership Audit

BUSINESS INFORMATION

Company Name

Company Address

Company City

State

Zip Code

Shipping Address (If different from above)

Company City

State

Zip Code

Company Phone (Main)

Company Email (If applicable)

Company Website

CONTACT INFORMATION

Primary

Primary Contact First Name

Primary Contact Last Name

Address (If different than the Company Address)

City

State

Zip Code

Phone Number

Accounting

Accounting Contact Last Name

Accounting Contact First Name

Address (If different than the Company Address)

City

State

Zip Code

Phone Number

Marketing

Marketing Operations Contact First Name

Marketing Operations Contact Last Name

Address (If different than the Company Address)

City

State

Zip Code

Phone Number

1. Does your store(s) offer any of the following: (Check all that apply.)

Tobacco

Liquor

Lottery

Pharmacy

2. STORE LOCATIONS – Please indicate the number of Stores/Locations of your Business below.
Please provide individual Store/Location information on the following page.

STORE/LOCATION INFORMATION

Store/Location

Store Location (Name and # if assigned)

Store Address

City

State

Zip Code

Store Phone Number and/or Direct Line

Store Manager Name

Store Manager Email

Assistant Store Manager Name

Assistant Store Manager Email

Store/Location

Store Location (Name and # if assigned)

Store Address

City

State

Zip Code

Store Phone Number and/or Direct Line

Store Manager Name

Store Manager Email

Assistant Store Manager Name

Assistant Store Manager Email

Store/Location

Store Location (Name and # if assigned)

Store Address

City

State

Zip Code

Store Phone Number and/or Direct Line

Store Manager Name

Store Manager Email

Assistant Store Manager Name

Assistant Store Manager Email

Store/Location

Store Location (Name and # if assigned)

Store Address

City

State

Zip Code

Store Phone Number and/or Direct Line

Store Manager Name

Store Manager Email

Assistant Store Manager Name

Assistant Store Manager Email

Store/Location

Store Location (Name and # if assigned)

Store Address

City

State

Zip Code

Store Phone Number and/or Direct Line

Store Manager Name

Store Manager Email

Assistant Store Manager Name

Assistant Store Manager Email

Start Over

For questions or more information about the Membership Audit or your Company Online Dashboard, contact Molly Talley, OGA Director of Operations at 614-512-6424, or molly@ohiogrocers.org