Name of Business: ____________________________________________________________________

Mailing Address: _______________________________________________________________


Street Address: ________________________________________________________________


City/State/Zip: _________________________________________________________________


Telephone No.: 1 + or Area Code (_________)_____________________________


Fax No.: 1 + or Area Code (_________)_____________________________

Type of Business: [____] Individual / [____] Partnership / [____] Corporation / [____] Other

Nature of Your Business: ________________________________________________________________

How Long in Business: ________Years ________Months

Federal Employer Identification No. ________________________ If Other _________________________

Check If Certified As A Small & Emerging Business With State of Louisiana:   ____ YES

List commodities or services in which your business would like to receive solicitations:

1. __________________________________________ 4. ______________________________________

2. __________________________________________ 5. ______________________________________

3. __________________________________________ 6. ______________________________________

I HEREBY CERTIFY THAT NO OFFICER, OWNER OR EMPLOYEE HAS A SUBSTANTIAL PART OR
CAPITAL INTEREST IN THE DESIGNATED BUSINESS AND WHO IS ALSO A FACULTY OR STAFF
EMPLOYEE OF SOUTHEASTERN LOUISIANA UNIVERSITY AND THAT ALL INFORMATION
FURNISHED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

Type Name: ___________________________________ Signature: ______________________________

Title: _________________________________________________ Date: _________________________

RETURN TO:

Southeastern Louisiana University Purchasing Department SLU 10800 Hammond, LA 70402

or   FAX TO:

(985) 549-3810

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