ATTENTION Courier |
(Signature Required) Deliver to RECIPIENT address only. No indirect delivery. Disregard any Signature Release. Recipient MUST be at least 21 years old, and not show signs of intoxication. |
FULFILLMENT HOUSE APPOINTMENT
NAME | ADDRESS |
__________________ | __________________ |
__________________ | __________________ |
__________________ | __________________ |
__________________ | __________________ |
I swear, under penalty of perjury, that all representations made herein are true and correct and, I understand that any misstatement or suppression of fact in an application or accompanying affidavit is ground for denial, withholding, or suspension of a permit in accordance with R.S. 26:84 and R.S. 26:282.
____________________
Print Full Name of Authorized Representative
____________________ ___________
Signature of Authorized Representative Date
La. Admin. Code tit. 55, § VII-335