Check Entity Type. Private For-profit Business, licensed to do business in the State of Alaska Non-Profit Organization Incorporated in the State of Alaska, or tax exempt under 26 U.S.C. 501(c)(3) Alaska Native Entity, as defined in 7 AAC 78.950(1) All applicants under this provision must submit with their signed Agreement, a Waiver of Sovereign Immunity, using the form provided as Appendix D to this Provider Agreement. Political Subdivision of the State (City, Borough or REAA)
Check Entity Type. Private For-profit Business, licensed to do business in the State of Alaska Non Profit Organization Incorporated in the State of Alaska, or tax exempt under 26 U.S.C. 501(c)(3) Alaska Native Entity, as defined in 7 AAC 78.950(1) All applicants under this provision must submit with their signed Agreement, a Waiver of Sovereign Immunity, using the form provided as Appendix D to this Provider Agreement. Political Subdivision of the State (City, Borough or REAA) DEPARTMENT OF HEALTH & SOCIAL SERVICES: Xxxxx Xxxxxx Signature of DHSS Authorized Representative Printed Name of Authorized DHSS Representative Grants & Contracts Manager Title of Authorized DHSS Representative Date DHSS CONTACTS:
Check Entity Type. Private For-profit Business, licensed to do business in the State of Alaska Non Profit Organization Incorporated in the State of Alaska, or tax exempt under 26 U.S.C. 501(c)(3) Alaska Native Entity, as defined in 7 AAC 78.950(1) All applicants under this provision must submit with their signed Agreement, a Waiver of Sovereign Immunity, using the form provided as Appendix D to this Provider Agreement. Political Subdivision of the State (City, Borough or REAA) PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES _ Signature of Provider Representative & Date Xxxxx Xxxxxx, Chief, Grants & Contracts Support Team _ Printed Name Provider Representative & Title DHSS Contacts & Mailing Addresses Provider Contact Name & Mailing Address: PROGRAM CONTACT Xxxxxxx Xxxx, _ Discovery Services Coordinator DPA Policy & Program Development Team _ 000 Xxxxxxx Xx Xxx 000 Xxxxx XX 00000 Phone 000-000-0000 _ Fax 000-000-0000 Cell 000-000-0000 _ xxxxxxx.xxxx@xxxxxx.xxx Provider Phone Number/ Fax Number: ADMINISTRATIVE CONTACT Xxxxxxx Xxxxx, Grants Administrator Grants & Contracts Support Team PO Box 110650 Provider’s Federal Tax ID Number: Juneau, AK 00000-0000 Phone 000-000-0000 Fax 000- 000-0000 xxxxxxx.xxxxx@xxxxxx.xxx
Check Entity Type. Private For-profit Business, licensed to do business in the State of Alaska Non-Profit Organization Incorporated in the State of Alaska, or tax exempt under 26 U.S.C. 501(c)(3) Alaska Native Entity, as defined in 7 AAC 78.950(1) All applicants under this provision must submit with their signed Agreement, a Waiver of Sovereign Immunity, using the form provided as Appendix D to this Provider Agreement. Political Subdivision of the State (City, Borough or REAA) Please email the completed Provider Agreement and supporting eligibility documentation to the following email address: XXX.XXX.Xxxxxx.Xxxxxxxx.Xxxxxxxxxx@xxxxxx.xxx. DEPARTMENT OF HEALTH AND SOCIAL SERVICES 7 AAC 81 GRANT SERVICES FOR INDIVIDUALS Revised June 23, 2006 This document is intended as an informational guide only. The Department of Health & Social Services makes no warranty, express or implied, of the accuracy of this document. A complete copy of State of Alaska Administrative Code can be accessed at the Alaska Legislature Infobase at xxxx://xxx.xxxxx.xxxxx.xx.xx/folhome.htm. However, to be certain of the current version of the statutes and regulations, please refer to the official printed version. Title 7. Health and Social Services.
