Business Application Form

Business Profile Data Form

Items in red are required.

Federal Tax ID Number (EIN): - or SSN: --
*Note: Vendor must have a Federal EIN or provide social security number to be eligible to bid.

Applicant's Business Name:
DBA (Doing Business As):
Business Address 1:
Business Address 2:
City:
State:
Zip:
Accounts Payable Address (If Different from above)
Accounts Payable Address 1:
Accounts Payable Address 2:
City:
State:
Zip:
Contact Person (First and Last Name):
Email Address:
Cell Phone Number:	--
Telephone Number:	--
Fax Number:	--

Business Structure: Check all that Apply

     Partnership
     Joint Venture
     Corporation
     Sole Proprietorship
     Limited Liability Company

Business Ownership: Check only if it applies

American Indian
American Indian Woman
Asian Pacific American

Asian Pacific American Woman
Asian Indian American
Asian Indian American Woman

Black American
Black American Woman
White American Woman

Is your company currently a certified DBE (Disadvantaged Business Enterprise) with any other company or organization i.e. DOTD? If so, please list below:

Registrations: If your business possesses the following registrations, give registration numbers.

Yes No

Louisiana State Sales Tax Number

Yes No

Louisiana State Contractor's License No.

Yes No

East Baton Rouge Occupational License

Yes No

East Baton Rouge Sales Tax Number

Date Established:

/ /

Number of Full Time Employees:

Are you, any member of your firm, or any close relative including major stockholders, employed by the East Baton Rouge City Parish Government? YES NO*

*If yes, list names, relationships to your firm and City-Parish Department/Division where employed.

NAME

RELATIONSHIP

DIVISION WHERE EMPLOYED

Commodity Enrollment (required)

Vendors must enroll in at least (1) commodity class-subclass; however, may enroll in as many as necessary. Enrollment into one (1) class to be included into all subclasses is NOT allowed.

Please fill out the 'Commodity Class-Subclass Enrollment' fields at the bottom of the page.

The City Parish Commodity Code list is accessible electronically at our website:

www.brgov.com/dept/purchase

Vendors without internet service may visit any local library or university offering free public access to the internet, or may visit the Purchasing office to manually review the Commodity Code list.

CONFLICT OF INTEREST Vendor shall exercise reasonable care and diligence to prevent any actions or conditions, which could result in a conflict with the best interests of City-Parish Government. This obligation shall apply to the activities of the employees and agents of Vendors in their relations with the employees and their families of owner, vendors, subcontractors, and third parties arising from contracts or purchase orders for furnishing goods or services to the City-Parish government. Contractor's efforts shall include but not be limited to, establishing precautions to prevent its employees from making, receiving, providing, or offering gifts, entertainment, payments, loans, or other considerations of more than nominal value.

BUSINESS ETHICS Vendor agrees to comply with all laws and lawful regulations applicable to any activities carried out in the name of or on behalf of the City-Parish government under the provision of City-Parish contracts or purchase orders including any amendments thereto. Vendor agrees that all financial settlements, billings and reports rendered to the City-Parish government, will reflect properly the facts about all activities and transactions handled for the account of the City-Parish government, which data may be relied upon as being complete and accurate in any further recording and reporting made by the City-Parish government for whatever purpose.

Further, company authorization should be obtained before completing this application. The Purchasing Director should be notified of any changes that would affect the statements made in this document.

Submitted by:
Name of Business:

Commodity Enrollment

Please enter the Class AND Subclass Numbers below for those goods and/or services for which you wish to be considered.

Class	Subclass

Class	Subclass

For security purposes please type the numbers and decimals exactly how it appears in the box above.

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