Fax Number. Email Address: Credentialing Contact: Telephone Number: Fax Number: Email Address: Address Information Federal Tax ID Number: National Provider Identification: Attach a completed W9 form for each Federal Tax ID number. Physical Address – physical location of the Facility THIS ADDRESS AND PHONE NUMBER WILL APPEAR ON THE WEBSITE PROVIDER DIRECTORY. Physical Address: Mailing Address Mailing Address: City State ZIP Phone: Fax: Contact Person: Email Address: Mailing contact information, if listed, will be utilized for all legal, contractual notices as defined in section 11.2 or 12.2 of the facility contracts. An email address must be included for this contact in order to access the online fee schedules. All notices will be sent electronically. Billing/Remit Address – for claims payments and remittance statements ALL BILLING INFORMATION BELOW MUST MATCH THE INFORMATION REFLECTED ON THE CLAIMS SUBMITTED. Name Submitted on Claims: Billing Office Name (if applicable): Billing Address: City State ZIP Phone: Contact Person: Email Address: Fax: Additional Location Federal Tax ID Number: National Provider Identification: Attach a completed W9 form for each Federal Tax ID number. Physical Address – physical location of the Facility THIS ADDRESS AND PHONE NUMBER WILL APPEAR ON THE WEBSITE PROVIDER DIRECTORY. Physical Address: Mailing Address- for correspondence/credentialing Mailing Address: City State ZIP Phone: Fax: Contact Person: Email Address: Billing/Remit Address – for claims payments and remittance statements ALL BILLING INFORMATION BELOW MUST MATCH THE INFORMATION REFLECTED ON THE CLAIMS SUBMITTED. Name Submitted on Claims: Billing Office Name (if applicable): Billing Address: City State ZIP Phone: Fax: Contact Person: Email Address: Please use copies of these pages to report any additional locations. Network Provider Laboratory Contract Signature Page The Office of Management and Enterprise Services Employees Group Insurance Division (EGID), and the facility incorporate by reference the terms and conditions of the Network Facility Contract into this signature page. EGID and the facility further agree that the effective date of the contract is the effective date denoted on the copy of the executed signature page returned to the facility. The original of the signed document will remain on file in the office of EGID. FOR THE FACILITY: Legal Name of Owner (Typed or Printed) Trade Name/DBA (Typed or Printed) Federal Tax ID Number Address of the Facility: Authorized ...
Fax Number. Email Address: Employer (billing information): Check if same as Corporate. Address:
Fax Number means a party’s facsimile number set out in the Notices clause of this agreement; GST has the same meaning as in the GST Law; GST Law has the meaning given to that term in A New Tax System (Goods and Services Tax) Xxx 0000 (Cth) and any other Act or regulation relating to the imposition of or administration of the GST; Insolvent means, in relation to a party:
Examples of Fax Number in a sentence
In case of Proprietorship/Partnership firms, name of the Proprietor/Partners with complete Postal Residential & Business address, Telephone Number, Fax Number, Mobile Number, & Email ID, if any ( in order of ------- % of shares) along with certified copy of registered documents of Partnership Deed.
Registered Head Office with Postal Address and Telephone Number, Fax Number, Mobile Number & Email ID.
In case of Limited Companies furnish a certified Photostat copy of the Memorandum Articles of Association along with the List of Directors, their addresses, Telephone Number, Fax Number, Mobile Number, & Email ID, if any.
Name and Designation of the Officer/complete Postal Address, Phone Number Mobile Number, Fax Number, Email ID etc.
Mumbai Office address with Telephone Number, Fax Number, Mobile Number & Email ID.
More Definitions of Fax Number
Fax Number. E-Mail Address: License number: _Active License? Yes No Is small generator facility eligible for Net Metering? Yes No INSURANCE DISCLOSURE The attached terms and conditions contain provisions related to liability and indemnification, and should be carefully considered by the interconnection customer. The interconnection customer is not required to obtain general liability insurance coverage as a precondition for interconnection approval; however, the interconnection customer is advised to consider obtaining appropriate insurance coverage to cover the interconnection customer’s potential liability under this agreement.
Fax Number or at any other address of which either of the foregoing shall have notified the other in any manner prescribed in this Section 10.01. For all purposes of this Agreement, a notice or communication will be deemed effective:
Fax Number. Email Address: Owner Name: is organized as a corporation in the state of State: . Owner Name: will be referred to as Owner throughout this agreement. Owner's Representative Owner will be represented by Name of representative (Owner's Representative) as described in this agreement.
Fax Number. 224 0000 Xxxex Number: 28030 DDBSIN Attention: Mr Jorgen Faenoe/Ms Maurxxx Xxx By: /s/ Mogexx Xxxxxxxxxxx By: /s/ Jorgen Faenoe ------------------------------ ----------------------------------- Name: Mogexx Xxxxxxxxxxx Name: Jorgen Faenoe ----------------------------- --------------------------------- Title: General Manager Title: Manager, Head of Credit and ---------------------------- Risk Management --------------------------------
Fax Number. 536 7816 Telex number : RS 24396 Attention : Ms Sxxxx Xxx / Ms Pxxxxxxx Xxx
Fax Number. 000-000-0000
Fax Number. Backup Contact: Street Address: City, State, Zip Code: Phone Number: FAX Number: TAX WITHHOLDRNG: Non Resident Alien Y* * Form 4224 Enclosed Tax ID Number CONTACTS/NOTIFICATION METHODS: ADMINISTRATIVE CONTACTS - BORROWINGS, PAYDOWNS, INTEREST, FEES, ETC. Contact: Street Address: City, State, Zip Code: Phone Number: FAX Number: PAYMENT INSTRUCTIONS: Name of Bank where funds are to be transferred: Routing Transit/ABA number of Bank where funds are to be transferred: Name of Account, if applicable: Account Number: Additional Information: MAILINGS: Please specify who should receive financial information: Name: Street Address: City, State, Zip Code: It is very important that all of the above information is accurately filled in and returned promptly. If there is someone other than yourself who should receive this questionnaire, please notify me of their name and FAX number and we will FAX them a copy of the questionnaire. If you have any questions, please call me at (617) 385-6292. PARTICIPANT INFORMATION