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Get LA Retail Keg Registration Form 2016-2024

Trade Name (Name listed on State Alcohol Permit) Location Address (Street, City, State, & Zip Code) Sales Person Permit Number Location Parish Business Phone Number Purchaser Information: Name of Purchaser (print/type full legal name) Date of Birth (month, day, & year) Age ID#, State (Driver s License, State ID, etc.) Phone Number Residence Address (Street, City, State, & Zip Code) Keg(s) Information (to be filled out by retailer): Date & Time of Purchase: at Keg Identification N.

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