LSU Supplier Registration

You are now entering the LSU Supplier Registration Form. This form must be completed by an authorized representative of the payee organization or individual.

A signed W-9 or W-8 form (PDF, JPG, or Microsoft Word document files no larger than 5 MB) must be submitted with the application to complete the enrollment process to obtain a LSU Supplier ID. The University must obtain the payee’s correct taxpayer identification number and legal name as it appears on his/her/its federal income tax return to report taxable payments made to suppliers and individuals.
LSU Employees are prohibited from completing the supplier registration form on behalf of the supplier/individual.
Missing information and documentation will delay the enrollment of your company in the LSU Supplier Database.

Please fill out all required fields and click the ‘Next Step’ button in each section. You will have a chance to verify/change any information and to add comments before submitting the registration to LSU Procurement.

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Please complete this form using a desktop web browser (Google Chrome, Apple Safari, Mozilla Firefox or Microsoft Internet Explorer 10+)

By completing this application, I hereby authorize that all information provided, including any and all personal or company data may be shared with LSU departments, suppliers and other governmental agencies to facilitate procurement transactions. This data will be retained according to LSU’s retention schedule. To learn more about privacy at LSU, please see the LSU Privacy Statement

Company/Individual Name:
Company Division/DBA Name:
Business URL:
Tax ID Type:
Tax ID (FEIN/SSN): (Do not enter dashes) (Must be 9 digits)
DUNS: (Do not enter dashes)
Submitted By: Submitted By First Name Submitted By Middle Name Submitted By Last Name
Submitted By Title:
Phone: Phone Extension (Enter numeric characters only, USA include Area Code)	✓ Valid Invalid number
Email:
LSU Department Name: (Identify name of LSU Department Name requesting goods or services)
LSU Department Contact: (Identify name of LSU Employee requesting goods or services)

Business Organization Type

Corporation	Corporation - Legal Services
Corporation - Medical Services	Limited Liability Company
Individual	Partnership
Other

Taxpayer Identification Number (TIN) Certification

A response must be provided for each statement shown below.

Under penalties of perjury, I certify that:

I am subject to backup withholding.

Yes No

I am a U.S. person (including a U.S. resident alien).

Yes No

The number (FEIN or SSN) shown on this form is my correct taxpayer identifcation number.

Yes No

If foreign supplier using all 999s, mark no as response to each statement.
Additional information and instructions regarding these certifications are found on the IRS Form W-9.

Diverse Supplier Classifications (optional: please check all that apply)

Certification documentation should be submitted with the application. Supplier must be certified to be classified in the LSU Supplier Database as a “Diverse Supplier”. For more information on certifications, visit https://www.lsu.edu/administration/ofa/supplierdiversity/certifications.php.

Minority Owned Business (MBE)

Woman Owned Business (WBE)

Disadvantaged Business Enterprise (DBE)

Disability-Owned Business Enterprise (DOBE)

Lesbian, Gay, Bisexual, Transgender-Owned Business Enterprise (LGBTBE)

Veteran-Owned Business Enterprise (VOB)

Small Business (Hudson Initiative, Emerging, etc.)

Affidavit: By marking any ‘Diverse Supplier Classifications’ on the LSU Supplier Enrollment form, the Supplier agrees, solemnly affirms, and attests that it possesses any claimed certification(s); and agrees to provide LSU with supporting evidence of such at any time upon request. The Supplier acknowledges that its willful and false claim of these certifications may result in contract cancellations and/or suspension or debarment proceedings. The Supplier further accepts the responsibility to promptly report any certification changes to LSU Procurement Services at suppliers@lsu.edu.

Suppliers must express their interest by self-enrolling in their desired State of Louisiana Region(s) in which they are willing and able to conduct responsible business. Suppliers must enroll in at least one (1) state delivery region; however, may enroll in multiple or all state regions as desired.
Please click here for a map of the state regions.

LSU campuses using the Supplier Database are located in the following state regions:

• Baton Rouge - Region 2
• Eunice - Region 4
• Alexandria - Region 6
• Shreveport - Region 7

Note: LSU AgCenter Research Stations are regionally located statewide

Check those State Regions in which you wish to participate/enroll:

1	2	3	4	5	6	7	8	All Regions
New Orleans	Baton Rouge	Thibodaux	Eunice	Lake Charles	Alexandria	Shreveport	Monroe

Mailing Addresses (known in Workday as Ship Addresses) must be a physical address and are used by LSU to send solicitations, addenda, purchase orders, change orders, and purchasing correspondence or transactions via E-Mail, Fax, USPS Mail and/or courier/express service.

Country:
Mailing Address 1:	Phone: Extension:	✓ Valid Invalid number
Mailing Address 2:	Toll Free Phone: Toll Free Extension:	✓ Valid Invalid number
City:	Fax:	✓ Valid Invalid number
State:
Zip:	Email:

Contact Name: Mailing Contact First Name: Mailing Contact Middle Name: Mailing Contact Last Name:
Contact Title:
Contact Phone: Contact Phone Extension	✓ Valid Invalid number
Contact Email:

Remit Address (required if different from Mailing Address information; used by LSU Accounts Payable & Travel to send payments and accounting correspondence).

Same as Mailing Address

Country:
Remittance Address 1:	Phone: Phone Extension:	✓ Valid Invalid number
Remittance Address 2:	Toll Free Phone: Toll Free Phone Extension:	✓ Valid Invalid number
City:	Fax:	✓ Valid Invalid number
State:
Zip:	Email:

Same as Mailing Contact

Contact Name: Remittance Contact First Name Remittance Contact Middle Name Remittance Contact Last Name
Contact Title:
Contact Phone: Contact Phone Extension:	✓ Valid Invalid number
Contact Email:

The University offers two electronic payment options, Paymode-X and ePayables, in lieu of payment by check to suppliers.

How does the ePayables payment process work?
Once the selection is made to receive payments by ePayables, a credit card account will be created, and the University will contact the supplier to provide the credit card information to be maintained in the supplier’s files. The credit card account will have unique security features, with an available fund balance of $0.00 until an invoice is approved for payment. When invoices are processed for payment, an electronic remittance advice will be sent via email to the listed remittance contact providing approval to charge the credit card and detailed invoice(s) information.

How does the Paymode payment process work?
To receive invoice payments by an ACH transaction, the supplier must obtain an account with Paymode-X. To enroll with Paymode-X, please click the following link: https://go.paymode.com/LouisianaStateUniversity/G-1JL9A4ZR. Once the supplier is activated with Paymode-X, payments will be made through ACH. When invoice payments are made, the listed supplier’s bank account will be debited, and an electronic remittance advice will be sent to the contact person via email to provide detailed payment and invoice(s) information. For additional information or questions regarding Paymode-X, please contact the Paymode-X Vendor Enrollment Team at 1-800-331-0974 or enrollment@paymode-x.com.

If additional assistance is needed, please contact Accounts Payable at (225) 578-1550 or aptravel@lsu.edu

Please make your selection below:

I would like to enroll my company in the ePayables and receive the invoice payments via a Credit Card Account

I would like to enroll my company in the Paymode and receive the invoice payments via an ACH Transaction

I would like to receive my payments by Check/Wire (required for individuals and foreign suppliers).

Are you, or any Officer, Director, Owner or Partner in this company, an employee or former employee of LSU?

Yes No

Is a direct family member of any of the above an employee of LSU?

Yes No

Please explain:
	(Please enter the employee’s name, department, and relationship to the company)


(Click Submit Request button only once. Clicking more than once may create duplicate applications and/or cause attachment errors.)

Available Supplier Groups:		Selected Supplier Groups:
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