California Lottery Vendor Contact Information Form

Contact Information

Vendor Name *

First Name *

Middle Initial

Last Name *

Address 1 *

Address 2

City *

State *

ZIP Code *

Office Phone *

Mobile Phone

Fax (optional)

Email Address *

Service Area

Select Primary Service Area *

Business Certifications

The Vendor is a certified Small Business

The Vendor is a certified Disabled Veteran Business Enterprise

Service Categories

Select up to four main categories and any applicable sub-categories.