*Indicates required fields                       *Last Name                       *First Name                 *Mailing Address   *City   *State   *Zip Code             *Home Phone Number   *Business Phone Number   Ext.                     *Email Address:                     Company/Store Name   #of locations

* State where store is located                     North Carolina   South Carolina   Other

* Is store (s) an interstate location?          Yes    No           * Number of employees (including self)          1-5    5-12    13 or more         * Hours of Operation          24 hours    Less than 24 hours           * Days of Operation          7 days    Less than 7 days           * Does store (s) sell fuel?          Yes    No           * Type of fuel          Branded    Unbranded    N/A         * Is there a gasoline agreement?        Yes    No           * Is the real estate        Owned    Leased           * If leased, is the term        1-5 years       5-10 years        10 years +     N/A         * Does the store (s) offer lottery?        Yes    No           * Does the store (s) offer prepared food?        Yes    No           * Is there a car wash?        Yes    No           * Number of competitors        None    1   2 or more         * Will the Seller finance?        Yes    No                   Sales Information                     * Gross Sales (Annual)                 * Inside Sales * Gasoline Sales * Food Sales                 * Other Income                     EBITDA (Earnings Before Income Taxes, Depreciation and Amortization                   * Sale Price               * Type of Representation requested    Exclusive    Non-Exclusive

* All information supplied herein, will be held in the strictest confidence