Hurricane Survey Form- Retail & Grocery Store
Government of the Virgin Islands of the United States Department of Licensing and Consumer Affairs Division Consumer Protection Services ( ) Convenience Store ( ) Small Store ( ) Gas Station w/ Deli ( ) Hardware Store ( ) Pharmacy ITEM BRAND NAME UPC NO. SIZE PRICE WITH A CHECK MARK, KINDLY INDICATE STORE CATEGORY, THANK YOU Date: ______________________________ Name of Establishment: ______________________________________________________________ Physical Address: ___________________________________________________________________ Mailing Address: ____________________________________________________________________ License Number: __________________________ Expiration Date: __________________________ Contact Person: ___________________________ Telephone: _______________________________ BUSIINESS NAME: ___________________________________ ITEM BRAND NAME UPC NO. SIZE PRICE
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Original source: https://dlca.vi.gov/forms/pdf/Hurricane_Survey_Form-Retail_and_Grocery_Store.pdf
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Government of the Virgin Islands of the United States Department of Licensing and Consumer Affairs Division Consumer Protection Services ( ) Convenience Store ( ) Small Store ( ) Gas Station w/ Deli ( ) Hardware Store ( ) Pharmacy ITEM BRAND NAME UPC NO. SIZE PRICE WITH A CHECK MARK, KINDLY INDICATE STORE CATEGORY, THANK YOU Date: ______________________________ Name of Establishment: ______________________________________________________________ Physical Address: ___________________________________________________________________ Mailing Address: ____________________________________________________________________ License Number: __________________________ Expiration Date: __________________________ Contact Person: ___________________________ Telephone: _______________________________ BUSIINESS NAME: ___________________________________ ITEM BRAND NAME UPC NO. SIZE PRICE