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Get LA Retailer Application 2006

Lease Type or Print Clearly in Black Ink Only. 1 BUSINESS NAME ADDRESS OF SALES LOCATION CITY STATE BUSINESS PHONE NUMBER ZIP CODE AREA CODE ( ) CONTACT NAME & TITLE CONTACT PHONE NUMBER AREA CODE ( ) BUSINESS MAILING ADDRESS (IF DIFFERENT) CITY 2 3 4 STATE Do you operate under a business trade name(s), or “doing business as” (d.b.a.) name(s)? FEDERAL I.D. NUMBER yes no LOUISIANA TAXPAYER --- IDENTIFICATION NUMBER TYPE OF BUSINESS GROCERY STORE/MARKET CONVENIENCE STO.

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