* Business Name:

* Address Line 1:

Address Line 2:

* City:

* State:

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* ZIP/Postal Code:

* Contact Name:

* Phone:

Fax:

* Email:

* Is your company authorized to collect AL Sales Tax?:

Yes
No

Permit Number:

    Minority, Woman or Disadvantaged Owned Business Information.

    * This business qualified by virtue of 51% or more ownership and active management by the following:

             American Indian or Alaskan native
             Hispanic
             Asian American
             African American
             Woman
             Disadvantaged

     * Has your firm been certified as a Minority, Woman or Disadvantaged Enterprise?

             Yes
             No

            If yes:

            Specify certifying agency:
            

            Date of certification:
            

     * Supplier Information