OFFICE INFORMATION. The apartment office address is listed on the first page of your lease agreement. The phone number is listed on the property sign as you enter the apartment property. Emergency numbers are listed on the bulletin boards in both the office and laundry (where a laundry is provided).
OFFICE INFORMATION. All Phone and Fax numbers must include area code OFFICE NAME PHONE # (###) ###-#### FAX # (###) ###-#### OFFICE STREET ADDRESS / PO BOX CITY POSTAL CODE OFFICE EMAIL SECTION 3 - NAME OF EMPLOYED SUPERVISED PERSONS ACCESSING THE SYSTEM ON YOUR BEHALF FIRST NAME SURNAME JOB TITLE PERSONAL EMAIL* FIRST NAME SURNAME JOB TITLE PERSONAL EMAIL* FIRST NAME SURNAME JOB TITLE PERSONAL EMAIL* FIRST NAME SURNAME JOB TITLE PERSONAL EMAIL* FIRST NAME SURNAME JOB TITLE PERSONAL EMAIL* *personal email is required in order to authenticate user when completing annual Data Access & Confidentiality Agreement SECTION 4 - NAME OF EMPLOYED SUPERVISED PERSON AUTHORIZED AS YOUR SIGNATORY* FOR PURPOSES OF ACCESS PROVISIONING AND DEPROVISIONING REQUESTS VIA THE IHA AMP FIRST NAME SURNAME JOB TITLE EMAIL
OFFICE INFORMATION. CDAnet Office Number: (Only if office is already sending e-claims, otherwise number will be assigned) Office Name: *Contact person: First Last *Address: *City: *Province: Postal Code: *Phone: ( ) *Software vendor: *Office administrative email: Preferred Office Language: English French AGREEMENT Once subscribed to the office a CDA Digital ID is required to send e-Claims. Sign in to the PSS website and download a CDA Digital ID. You can authorize dental office owner(s) and office staff to download CDA Digital ID(s) used for sending e-claims with CDAnet and ITRANS Claims Service I give permission for the office owner and administrator(s) to download and install my CDA Digital ID at this office: Yes No By signing below I certify that I am a duly licensed dentist and a member of the provincial/territorial dental association. I have read and agree to all the terms and conditions stated in the attached CDA Practice Support Services Subscriber Agreement and related CDAnet/ITRANS Service Schedule. See xxx.xxxxxx.xx for agreement updates and other information. *Dentist signature (no stamps): *Date: The Office will be notified when the subscription has been processed. 0000 Xxxx Xxxxx Xxxxx, Xxxxxx, Xxxxxxx X0X 0X0 Tel.: (000)000-0000 Email: xxxxxx@xxx-xxx.xx | xxx.xxxxxx.xx 2018-06-12 v4.1 1 CDA Practice Support Services Subscriber Agreement Canadian Dental Association (CDA) Version 1.1, Dated April 15, 2018 xxxxx://xxxxxxxx.xxx-xxx.xx/Home/Subscriptions READ THIS CDA PRACTICE SUPPORT SERVICES SUBSCRIBER AGREEMENT (THE “SUBSCRIBER AGREEMENT”) AND RELATED SCHEDULE CAREFULLY. It applies to certain services provided by the Canadian Dental Association (“CDA”). Signing the attached CDAnet and ITRANS Claims Service Subscription Agreement Form at the end of this Subscriber Agreement means that You agree to be bound by it.
OFFICE INFORMATION. Office name: Industrial Property Office of the Czech Republic (CZ) Tax / VAT: CZ48135097 Address: Antonina Xxxxxxx 0x 000 00 Xxxxx 0 Xxxxxx Xxxxx Xxxxxxxx Phone: +00 0 000 000 000 E-mail: xxxxx@xxx.xx Office head: Xx Xxxxx Xxxxxxxxxx President
OFFICE INFORMATION. Federal Tax ID Number: (Attach a completed W-9 form for each Tax ID number) Primary office or clinic name: Physical Address: (City) (State) (Zip) Telephone number: ( ) Fax number: ( ) Contact Person: E-mail Address: Supervising Physician: Mailing Office or clinic name: Mailing Address: (City) (State) (Zip) Telephone number: ( ) Fax number: ( ) Contact Person: E-mail Address: Billing Office or clinic name: Billing Address: (City) (State) (Zip) Telephone number: ( ) Fax number: ( ) Contact Person: E-mail Address: ADDITIONAL OFFICE LOCATION (S) Federal Tax ID Number: (Attach a completed W-9 form for each Tax ID#) Office or clinic name: Office Address: (City) (State) (Zip) Telephone number: ( ) Fax number: ( ) Contact Person: E-mail Address: Supervising Physician: Mailing Address: (City) (State) (Zip) Telephone number: ( ) Fax number: ( ) Contact Person: E-mail Address: Billing Office or clinic name: Billing Address: (City) (State) (Zip) Telephone number: ( ) Fax number: ( ) Contact Person: E-mail Address:
OFFICE INFORMATION. There is information posted on the wall to the right of the office computer. This is the place to look if you need a phone number for somewhere on campus, emergency services, or Xx. Xxxxxx’.
