Louisiana Responsible Vendor BAR CARD

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First name

Last name

Email address

Username

Password

Middle Initial

Mailing Address Including Apt. or Unit #

City

State

Zip Code

Phone Number (No Dashes)

Birthdate Month

Birthdate Day

Birthdate Year

Gender

Height

Weight

last 4 of Social Security Number

State Drivers License/ State ID Card Number *This is required by the state!

State Drivers License/ State ID Card was issued by which state