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Supplier Registration/Information Form

Please provide the following required information to be included on the Â黨ÐÇ¿Õmv bidder list.

Mailing Address

Remittance Address

(if different from mailing address)

LMC is committed to increasing special interest group vendor participation. Please help us meet our commitments by checkingÌýappropriate information below if applicable:

Minority groups include:

• Black/African American
• Hispanic (Mexican, Puerto Rican, Cuban, Central or South American, other Spanish origin, regardless of race)
• Asian (including Pacific Islander)
• American Indian (including Alaskan native)
• Handicapped
• Disabled American Veteran
• Vietnam Era Veteran

Bank Reference

Information about your services

Certification

The undersignedÌýcertifies that the information contained herein is correct. I understand that misrepresentation may be cause for removal from the Bidders Mailing List and any other penalties allowed by law. Further, I affirm that this company does not discriminate in employment practices because of race, color, creed, sex, age, height, weight, handicap or religious practice.