Louisiana Non-Gaming Vendor Affidavit And Release (Page 3 of 4) in pdf

LOUISIANA NON-GAMING VENDOR AFFIDAVIT AND RELEASE

(To be completed by non-gaming vendors doing business in Louisiana only)

The undersigned swears that he/she is the duly authorized representative of ___________________________ (Company Name)

making this application and the foregoing statements, including statements and data provided in any attachment(s) to the application,

are true and correct and include all material information necessary to identify and explain the operation of the business as well as to

attest to its ownership pursuant to the following Sections. In completing Sections I – III, please refer to the above definitions and

only check those that apply to your business.

Section I - Are you a Louisiana Business per the above definitions?

Yes

Section II – Please check all boxes that are applicable and refer to the above definitions in this Affidavit.

Louisiana Minority Business Enterprise or Louisiana Minority Owned Business

Louisiana Women's Business Enterprise or Louisiana Woman Owned Business

I am not a Louisiana Minority or Women Owned Business Enterprise per the above definitions.

I am a Minority and/or Women Owned Business Enterprise and am not considered a Louisiana Business

Section III – If you are a minority or women owned business, please complete the following:

Do you have proof of status as a Minority or Women Owned Business Enterprise by a third party certification agency?

Yes

If you answer Yes, please also submit a copy of your current certificate from the third party certification agency. You can upload

this directly in your supplier registration form located on

If the undersigned is requesting Boyd Gaming to rely on the certification of another organization, the undersigned hereby

affirmatively represents that the ownership and control of the business entity has not changed in any manner that would cause de-

certification by said organization.

Further, the undersigned understands that any false statements, omissions or material misrepresentations will be grounds for denial of

certification, de-certification and/or for terminating any contract(s) which may be awarded and for initiating action under Federal and

State Law concerning false statements. The undersigned further agrees to provide Boyd Gaming with any additional information that

it deems necessary to make accurate assessments of this business’ eligibility as a Louisiana-owned, Louisiana minority-owned, or

Louisiana woman-owned enterprise. If there should be any change in ownership or control of this business, or in any other

information submitted, the undersigned agree(s) to notify Boyd Gaming immediately

____________________________________

______________________

_____________________

Signature

Date

Phone Number

_____________________________________

________________________

Printed Name

Title

SWORN TO AND SUBSCRIBED before me, Notary, this ____ day of _______________, 20____.

___________________________________________________

Notary Public

NOTARY SEAL

___________________________________________________

In and for the Parish / County of

Updated February, 2012

Louisiana Non-Gaming Vendor Affidavit And Release Page 3

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