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PrintRouteSave AsSaveTo CatalogARMY & AIR FORCE EXCHANGE SERVICESOURCE LIST APPLICATIONDATETO: (enter name & address of Exchange purchasing activity)INITIAL APPLICATIONREVISED APPLICATIONSECTION I - GENERALThis is an application to be added to the Exchange source file to provide the merchandise, food, supplies, equipment, services orconstruction indicated herein. Send an application to all Exchange activities where you desire to be included in the source file. Theapplication must be signed by an officer of your firm. If you fail to respond to solicitations or presolicitation notices it will be understoodby the Exchange to indicate lack of interest and concurrence in the removal of your name from the source files for the items/servicesconcerned.SECTION II - SOURCE FILE DATAPERSON(S) AUTHORIZED TO COMMIT YOUR FIRM CONTRACTUALLYFIRM NAME & ADDRESS (enter complete address, includingzip code, actual street address preferred)NAMEEMAILTITLEa.b.c.TIN NO.E-MAIL: (required)TELEPHONE NO.FAX NO.ADDRESS TO WHICH SOLICITATIONS ARE TO BE MAILED(If different from above)DUNS NO.TYPE OF ORGANIZATIONTYPE OF BUSINESSINDIVIDUALMANUFACTURER OR PRODUCERPARTNERSHIPREGULAR DEALERCORPORATION, INCORPORATIONIN THE STATE OR COUNTRY OFSERVICE ESTABLISHMENTCONSTRUCTION FIRMOTHER (specify):OTHER (specify):TYPE OF OWNERSHIP: (check only where the contract is to be performed in the UnitedStates, its possessions and Puerto Rico)VETERAN-OWNED BUSINESSSMALL BUSINESSYESYESYESNOTOTAL SALES FOR LASTTWELVE MONTHSMINORITY BUSINESS ENTERPRISE(see definition below & check appropriate box)SMALL DISADVANTAGED BUSINESSWOMEN-OWNED BUSINESS(see definition below)OTHERSERVICE DISABLED VETERAN-OWNED BUSINESS(see definition below)INDICATE IF OWNER OR OFFICER IS ACTIVE The term "minority business" means a business concern (1) which is at least 51 percentNO MILITARY, U.S. GOVERNMENT EMPLOYEE, OR owned by minority group members; or in the case of any publicly owned business, at 51RETIRED REGULAR ARMY/AIR FORCE OFFICER. percent of the stock of which is owned by one or more minority group members (2) whoseINDICATE IF AN OWNER OR OFFICER IS AN management and daily business operations are controlled by one or more such minorityIMMEDIATE FAMILY MEMBER OF ONE OF group members. For purposes of this definition, minority group members includeNO ABOVE LIVING IN SAME HOUSEHOLD, ANDAsian-Pacific Americans,African Americans,Hispanic Americans,PROVIDE (1) NAME, (2) RANK/GRADE, (3)Native Americans (such as Alaskans and AmericanRELATIONSHIP,(4)JOBTITLE,(5) andIndians,ORGANIZATION/AGENCY AND (6) LOCATION.The term "women-owned business" means a business that is at least 51 percent owned by a(Use separate sheet or reverse side)woman or women who also control and operate it. "Control" in this context means exercisingthe power to make policy decisions. "Operate" in this context means being actively involved inthe day-to-day management.INDICATE IF AN OWNER OR OFFICER OF THEThe term "small disadvantaged business" means a small business concern which is at leastFIRM OR THE FIRM OR A RELATED FIRM HASBEEN CONVICTED OF A FELONY RELATED TO 51% unconditionally owned by one or more individuals who are both socially and economicallyNO A BUSINESS TRANSACTION, OR HAS BEEN disadvantaged, or a pubically owned business that has at least 51% of its stock unconditionallyowned by one or more socially or economically disadvantaged individuals.SUSPENDED OR DEBARRED.SECTION III - CERTIFICATIONIf former military or Exchange employee indicate separation date:YESI certify that the information given above is correct and that owners, officers, and related firms are not now suspended or debarred by anyagency of the U.S. Government.NAME AND TITLE (print or type)SIGNATURESECTION IV - CATEGORIES OF MERCHANDISE, FOOD, SUPPLIES, EQUIPMENT, SERVICES & CONSTRUCTIONIndicate on the reverse side the categories of items, services or construction that you are interested in providing to the Exchange.EXCHANGE FORM 4200-010 (REV SEP 20) (Prev Editions Obsolete)EOP 65-01

SECTION IV-A - MERCHANDISE, FOOD, SUPPLIES & EQUIPMENTList the items you wish to sell to the Exchange. You may attach a separate listing, and/or catalogs, as needed:ItemItemItemSECTION IV-B - SERVICES AND CONSTRUCTIONIndicate below the categories of services or construction you are interested in providing. Also indicate on an attached sheetor in the remarks section below the geographical areas/installations you are interested in serving.SERVICES1. Customer Related Services:Barber ShopsBeauty ShopsTailor-Made/Made-to-MeasureMilitary Uniforms/ClothingSpecialty Type Services (keymaking, bronzing, engraving,monogramming, trophies,plaques, etc.): (list)Laundry and Dry CleaningClothing AlterationsOptical DispensingFloral Service (Shop/Wire)Watch/Jewelry RepairShoe RepairOther: (list)Other (list)3. Vending Services:Soft Drinks - Bottle/Can/CupBeer (vending machine rentaland service only)Full-Line (hot and cold cupbeverages, juices, hot andcold food, pastry, chips,candy, cigarettes, etc.)Cigarette/CigarsBulk (candy, gum balls, nuts,novelties, etc.)Postage erette (washers, dryers,dry cleaners, and soap andbleach dispensers)Pinball/Games/Pool Tables/Music Machines/ScalesMassage ChairsSale of Handicraft/PaintingsItems: (list)DentalTelecommunications ServicesPet GroomingOther: (list)Custom Picture FramingPhotographic ProcessingHome Delivery ServicePortrait StudioPictorial Review/YearbookGarage/Auto RepairCar/Trailer Rental2. Food Services:Theater Refreshment StandMobile Ice Cream/Sno-ConesMobile Food Service - Pizza/Fried ChickenSpecialty Food ServiceFacility - Pizza/Fried ChickenSnack Bar - Sandwiches/Short OrdersEquipment/Appliance RentalTelevision RentalRadio/Television/ApplianceService RepairBicycle/Small Motor andLawn Mower RepairLiving Quarters Cleaning/Lawn CareMiniature GolfOptical4. Support Services (Used bythe Exchange):Vehicle (Cars/Trucks/Trailers)Repair and MaintenanceMHE Repair and MaintenanceHeating/Air Conditioning/Refrigeration EquipmentRepair and MaintenanceOffice Machine Repair andMaintenanceService Station EquipmentJanitorial ServicesSecurity Guard ServicesArmored Car/Courier ServicesLinen/Uniform RentalRental/Lease of Trucks/Tractor TrailersMHE RentalRefuse CollectionOther: (list)TV ChairsCONSTRUCTIONA. TYPE bing5.Other (specify below):B. TYPE CONSTRUCTION:1.C. DOLLAR VALUE:New1.Under 200,000Renovation2.Over 200,000SECTION V - REMARKS(REVERSE EXCHANGE FORM 4200-010)Page 2

SERVICES LISTINGSAutomotive Service ConcessionAuto DetailingStereo/Alarm InstallationWindow Tinting/Windshield RepairAuto Parts StoreCar Care CenterQuick Lube CenterOther(Specify)Commodity ConcessionArts and CraftsBook StoresBrass/Bronze/Pewter/Metal wareCandy - mas/SeasonalClothing/ yclopedia SalesFamily old/JewelryLeather goodsNutrition CenterOffice ts MerchandiseOther(Specify)Vending ies VendingBulk WaterCar Vacuum/Car Wash Coin OperatedDigital Photo PrintingDVD/Movie RentalEnergy/Sport/Isotonic DrinksFull Line VendingIce Cream/Frozen FoodKiddie RidesLaundromatLocker VendingNewspaper VendingPopcorn VendingProphylactic/Sanitary NapkinRecycle/Reverse VendingSoft Drink Vending - Bottle/Can/CupSoap/Bleach DispenserOther(Specify)EXCHANGE FORM 4200-010 (REV SEP 20) (Prev Editions Obsolete)StampsOther(Specify)Health ServicesAudiologyDental ClinicMassage ces ConcessionAlterationsAppliance RepairBarberBeautyBusiness CenterCar RentalCarnivalComputer/Electronics RepairCustom Picture FramingDay SpaEmbroidery/Monogramming ServiceEngraving/Trophy/PlaquesEquipment & TV RentalEquipment RepairFlower ShopFormal Wear Rental/SalesFurniture RentalGift Wrap ServicesHousekeepingInfant PhotographyLaundry/Dry CleaningLocker Storage/WarehouseNail SalonPack and WrapPet Shop/Pet GroomingPhoto Processing/1 Hr PhotoPortrait Studio/Painting/SketchingShoe RepairTailor Made ClothingTaxi/ShuttleTruck/Trailer RentalT-Shirts/Personalized ClothingUnit Photography/Year BookVideo RentalWatch/Jewelry RepairOther(Specify)Page 3

SERVICES LISTINGSFood Concession ServicesAsian FoodBagel ShopBakeryBarbecueHamburgers/HotdogsCandy ShopChickenCoffee/Espresso ShopCookie ShopDeli ShopDonutsFrozen YogurtIce CreamJuice/Smoothie BarKebab/GyroMobile FoodMobile Ice CreamPizzaSandwichSnack BarSnow Cones/Shave IceOther(Specify)Telecommunications ServicesCable TV ServiceCommunication CenterInternet ServicesLong Distance Phone ServicesPre-Paid/Debit Telephone CardsSatellite TV ServicesTelephone, Coin OperatedTelephone, Residential – Local & LDWireless – Cellular or PCS ServicesOther(Specify)Support ServicesBicycle Assembly/RepairDelivery ServiceEquipment/Merchandise RepairJanitorialLinen/Uniform RentalPrintingRing Sizing/Jewelry RepairSecurity GuardOther(Specify)EXCHANGE FORM 4200-010 (REV SEP 20) (Prev Editions Obsolete)Page 4

LOCATION LISTINGS-CONUSCONUS Continental United StatesAll CONUS LocationsAlabamaFort McClellanGunter Air Force BaseMaxwell Air Force BaseRedstone ArsenalFort RuckerAlaskaEielson Air Force BaseElmendorf Air Force BaseFort GreelyFort RichardsonFort WainwrightArizonaDavis-Monthan Air Force BaseFort HuachucaLuke Air Force BaseYuma Proving GroundArkansasLittle Rock Air Force BasePine Bluff ArsenalCaliforniaBeale Air Force BaseEdwards Air Force BaseFort Hunter-LiggettFort IrwinLos Angeles Air Force BaseLos Alamitos AFRCMarch Air Force BaseMcClellan Air Force BasePresidio of MontereyCamp ParksCamp RobertsSharp Army DepotCamp San Luis ObispoTravis Air Force BaseVandenberg Air Force BaseColoradoUSAF AcademyBuckley AFBFort CarsonPeterson Air Force BaseDelawareDover Air Force BaseDistrict of ColumbiaAndrews Air Force BaseBolling Air Force BaseFort McNairU.S. Soldier’s & Airmen’s HomeFloridaEglin Air Force BaseHomestead Air Force BaseHurlburt FieldMacDill Air Force BaseEXCHANGE FORM 4200-010 (REV SEP 20) (Prev Editions Obsolete)Patrick Air Force BaseSouthern Command HQTyndall Air Force BaseGeorgiaFort BenningDobbins Air Force BaseFort GordonHunter Air Force BaseMoody Air Force BaseRobins Air Force BaseFort StewartHawaiiAliamanu Military ReservationAmerican Samoa (Hawaii)Kwajalien (Hawaii)Maui (Hawaii)KMR (Hawaii)Bellows Air Force StationHickam Air Force BaseHelemano Military ReservationPohakuloa Military ReservationSchofield BarracksFort ShafterTripler Army Medical CenterWheeler Air Force BaseIdahoGowen FieldMountain Home Air Force BaseIllinoisRock Island ArsenalScott Air Force BaseIndianaFort Benjamin HarrisonKansasFort LeavenworthMcConnell Air Force BaseFort RileyKentuckyFort CampbellFort KnoxLouisianaBarksdale Air Force BaseFort PolkMarylandAberdeen Proving GroundFort Detrick/Site RFort George G. MeadeSite R/Raven Rock ComplexWarfield Air National GuardMassachusettsCape Cod AFSHanscom Air Force BaseNatick LabWestover Air Force BaseMichiganBattle Creek Air National GuardSelfridge Air National GuardPage 5