APPLICATION TO PARTICIPATE
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GEORGIA LOGOS
General Manager:
Bill Jones
Office Manager:
Bonnie Evans
6597 Peachtree Industrial Blvd
Suite A
Norcross, Georgia 30092
Toll Free: 800-783-2361
Phone: 770-447-6399
Fax: 770-447-6537
Hours: Mon-Fri 8a-5p
Advertiser Information
Name on Logo:
Store #:
Advertiser Address:
City:
State:
Zip Code:
Phone:
Website:
Is the location currently open for business?
Yes
No
Business Location Data
Interstate / Route:
Exit / Crossroad Name:
Exit / Interchange #:
Distance and Direction from Exit:
(Example: 0.8 miles East of the Exit Ramp)
County:
Billing Information
Business Type:
Corporately Owned
Individually Owned
Franchisee
Name / Owner:
Billing Address:
City:
State:
Zip Code:
Contact Name:
Contact Email:
Contact Phone:
Contact Fax:
Service Provided
Not all may be required for participation
Service:
Gas
Food
Lodging
Camping
Attraction
Pharmacy
Available at Location (check all that apply):
Unleaded Fuel
Diesel Fuel
Alternative Fuel
Specify Type:
Oil
Tire repair service or information on available tire repair service in the area
Water for vehicle batteries and / or radiators
Compressed air for tire inflation
Free sanitary restroom facility for each sex with
Lock
Sink for washing
Flush toilet
Tissue and sanitary towels or drying device
Free drinking water
Free cups for drinking water
Telephone available for public use
On premise attendant to collect monies
The facility has the appropriate state and local licensing for service of food
Indoor seating available for a maximum of
Available at Location (check all that apply):
Free sanitary restroom facility for each sex with
Lock
Sink for washing
Flush toilet
Tissue and sanitary towels or drying device
Free drinking water
Free cups for drinking water
Telephone available for public use
The facility has the appropriate state and local licensing to provide lodging
Total # of sleeping units
Off-street parking is available for guests
Total # of parking spaces available
The facility is open 24 hours a day, 7 days a week
Each unit has a private entrance
Each unit has a private bathroom with hot and cold water with a tub or shower
Telephone available for public use
The facility has the appropriate state and local licensing to provide camping service
Do you provide accommodations for:
Trailers
Recreational Vehicles
Tents
The facility is open 24 hours a day, 7 days a week during the season
Open Season:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
day of
January
February
March
April
May
June
July
August
September
October
November
December
through
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
day of
January
February
March
April
May
June
July
August
September
October
November
December
or
Year-round
Total # of campsites available
Available at Location (check all that apply):
Electrical outlets for all types of camping vehicles
Free sanitary restroom facility for each sex with
Lock
Sink for washing
Flush toilet
Tissue and sanitary towels or drying device
Bath or shower facilities
Free drinking water
Free cups for drinking water
Telephone available for public use
On premise attendant to collect monies
The facility has the appropriate state and local licensing
Generally describe your location / facility: (for example: water park or museum)
Open Season:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
day of
January
February
March
April
May
June
July
August
September
October
November
December
through
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
day of
January
February
March
April
May
June
July
August
September
October
November
December
or
Year-round
# of Parking Spaces Available
Free sanitary restroom facility for each sex with
Lock
Sink for washing
Flush toilet
Tissue and sanitary towels or drying device
Estimated annual attendance
The facility currently has other existing traffic control devices, such as supplemental guide signs (green or brown), or other signage provided by the state directing traffic specifically to or from your facility
The facility is open 24 hours a day 7 days a week year-round
There is a licensed pharmacist at the location 24 hours a day 7 days a week year round
Hours of Operation
Monday
1
2
3
4
5
6
7
8
9
10
11
12
:
00
15
30
45
am
pm
to
1
2
3
4
5
6
7
8
9
10
11
12
:
00
15
30
45
am
pm
or
24 Hours
Tuesday
1
2
3
4
5
6
7
8
9
10
11
12
:
00
15
30
45
am
pm
to
1
2
3
4
5
6
7
8
9
10
11
12
:
00
15
30
45
am
pm
or
24 Hours
Wednesday
1
2
3
4
5
6
7
8
9
10
11
12
:
00
15
30
45
am
pm
to
1
2
3
4
5
6
7
8
9
10
11
12
:
00
15
30
45
am
pm
or
24 Hours
Thursday
1
2
3
4
5
6
7
8
9
10
11
12
:
00
15
30
45
am
pm
to
1
2
3
4
5
6
7
8
9
10
11
12
:
00
15
30
45
am
pm
or
24 Hours
Friday
1
2
3
4
5
6
7
8
9
10
11
12
:
00
15
30
45
am
pm
to
1
2
3
4
5
6
7
8
9
10
11
12
:
00
15
30
45
am
pm
or
24 Hours
Saturday
1
2
3
4
5
6
7
8
9
10
11
12
:
00
15
30
45
am
pm
to
1
2
3
4
5
6
7
8
9
10
11
12
:
00
15
30
45
am
pm
or
24 Hours
Sunday
1
2
3
4
5
6
7
8
9
10
11
12
:
00
15
30
45
am
pm
to
1
2
3
4
5
6
7
8
9
10
11
12
:
00
15
30
45
am
pm
or
24 Hours
Other information you wish to provide:
Certification
I
(Name of Applicant)
,
(Title of Applicant)
, of
(Business)
certify that the information I have provided is true and correct, and I will inform the program administrator of any changes to this information that may affect the availability of the service provided and our eligibility for participation. I further certify that we do not discriminate on the basis of color, religion, sex, nationality, or creed and we comply with the Americans with Disabilities Act as applicable to the service we provide. I understand that either the State Agency with oversight of this program or the program administrator may make inquiries or inspections to ensure that the minimum eligibility requirements for participation are being met.
Application Fee may apply and need to be sumbitted before your application can be processed.
Please refer to the "Participation Fees" section accessible from the left tool bar.
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