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: City State ZIP Phone: Fax: Contact Person: Email Address: Mailing Address- for correspondence/credentialing 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 MUST MATCH THE INFORMATION REFLECTED ON SUBMITTED CLAIMS Name Submitted on Claims: Billing Office Name (if applicable): Billing Address: City State ZIP Phone: Fax: Contact Person: Email Address: 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: City State ZIP Phone: Fax: Contact Person: Email Address: Mailing Address- for correspondence/credentialing 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 MUST MATCH THE INFORMATION REFLECTED ON SUBMITTED CLAIMS 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 Department Of Rehabilitation Services Network Infusion Therapy Contract Signature Page When signed by both parties below, this constitutes agreement and acceptance of all terms and conditions contained in the Infusion Therapy Contract to be effective the date...
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
Payment Terms: Firm Name: Address: Telephone Number: Fax Number: Email: Authorized Signature: Name of Signee: Title: Date: *All bids submitted are taken by the University as offers to sell by the Proposer and acceptance shall occur only by the issuance of a University purchase order or where appropriate, upon the execution of a written contract.
Bidder/Proposer’s Registered Name Address City, State, Zip E-Mail AddressE.I.No. / Federal Social Security Number Used on QuarterlySignature of Person Authorized to Enter Date into Contracts for Bidder/Proposer Printed Name and Title(Area Code) Telephone Number / Fax Number State Business License Numberin WA, also known as UBI (Unified Business Identifier) NumberFederal Tax Return, U.S. Treasury Dept.
The detailed address and telephone numbers / mobile numbers / Fax Number are as below.
Such notice shall be sent directly to the Department and shall be mailed, emailed, hand delivered or sent by facsimile transmission to (State Representative’s Name, Address & Fax Number).
Postal address/ Email Address/ Fax Number/ Mobile Number and Landline Number of the P.P/consultant/RQP (for B2 cat.
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. 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 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. 000-000-0000
Fax Number. 536 7816 Telex number : RS 24396 Attention : Ms Sxxxx Xxx / Ms Pxxxxxxx Xxx
Fax Number. Email address: …………………………………………………………………………………. Contact(s): ………………………………………………………………………………………. Address for Invoice : ................................................................................................. ................................................................................................. ................................................................................................. Address for Collection: …………................................................................................... ................................................................................................. ................................................................................................. Container location: …………................................................................................... Agreement start: ……………………………………………………………………... Period: Twelve months on annual automatic renewal until termination according to the conditions on page 4. Please confirm the services you want to continue below: REFUSE BINS Bin Number of bins required Collected Weekly Collected Fortnightly 240 litre 660 litre 1100 litre PAPER & CARDBOARD RECYCLING BINS Bin Number of bins required Collected Weekly Collected Fortnightly 240 litre 660 litre 1100 litre GLASS RECYCLING BINS Bin Number of bins required Collected Weekly Collected Fortnightly 240 litre 360 litre PLASTICS & CANS RECYCLING BINS Bin Number of bins required Collected Weekly Collected Fortnightly 240 litre 360 litre 660 litre 1100 litre For our current prices for 2014/15 see our webpages - xxx.xxxxxxx.xxx.xx/xxxxxxxxxxxxx Prices for each coming year will be notified to you every March. Our special webpages - xxx.xxxxxxx.xxx.xx/xxxxxxxxxxxxx - include guidance on waste legislation and reduction and recycling tips as well as links to more detailed sources of advice. Thank you for using our local, safe and reliable waste and recycling collections. Conditions
Fax Number. Email Address: Check here to confirm that the employment status reporting option has been selected in paragraph 5 of this agreement and that if you selected option (a) that you have identified the set reporting day of the week. Teamsters Local Union No: Period Covered by Participation Agreement: From: / / To: / / ACCEPTED FOR THE BOARD OF TRUSTEES MICHIGAN CONFERENCE OF TEAMSTERS WELFARE FUND Signature of Authorized Representative Name of Authorized Representative/Title (please print) Date Signature Xxxx X. Xxxxxxxx /Executive Director