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2. Company Name
4. Address
   For inquiries, mail outs, etc.
6. City
7. State
8. Zip Code
10. Remittance Address
    Address where payments are to be mailed.
12. City
13. State
14. Zip Code
16. Phone
17. Fax
19. Email
20. Federal ID Number
22. Please Note:

    The selection and awarding of all proposals and bids must comply with the Louisiana Code of Governmental Ethics (LRS 42:1101) and other federal restrictions when federal funds are involved.

24. Names of Officers, Members or Owners of Concern, Partnership, Etc.
26. President
28. Vice President
30. Secretary / Treasurer
32. List classes of equipment, supplies, materials, and/or services you sell or offer:
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field