CONTRACT NAME The name of this contract is Prepaid Mental Health Plan - Four Corners Community Behavioral Health Inc.
Contractor Name Business License #: Address: City, State, Zip Code: Telephone: Facsimile: Email: * If you are an independent contractor you are required to obtain a business license with the City of Thousand Oaks. Contractor certifies under penalty of perjury that Contractor is a Sole Proprietor Corporation Limited Liability Company Partnership Nonprofit Corporation Other [describe: ]
Project Name Register ASIC
Print Name Designation ...................................
COMPANY NAME The Members may change the name of the Company or operate under different names, provided a majority of the Members agree and the name complies with Section 00-00-000 of the Act.
Witness Name Address: The Corporate Seal of THE SECRETARY OF STATE FOR EDUCATION affixed to this deed is authenticated by: ……………………….. Duly Authorised ANNEXES
Name of Xxxxx(s) 2. The named person's role in the firm, and
Full Name Position: ................................................ Position: ................................................ Date: ..................................................... Date: .....................................................
Purchase Order Contact Name Purchase Order Contact Name. This person is responsible for receiving Purchase Orders from TIPS. Xxxxx Xxxxxx Purchase Order Contact Email Purchase Order Contact Email xxxxx@xxxxxxxxxx.xxx 2 3
FULL NAME OF AGREEMENT The full name of this Agreement is the PDL NPDL/PFLG Slot Charter Agreement ("Agreement").