PLEASE TYPE OR PRINT CLEARLY Sample Clauses

PLEASE TYPE OR PRINT CLEARLY. THANK YOU.
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PLEASE TYPE OR PRINT CLEARLY. RESERVATION INFORMATION
PLEASE TYPE OR PRINT CLEARLY.  Individual providers must enter their last name, first name and middle initial. All other applicants (e.g., a licensed business) must enter the complete business name as licensed/certified.  If the applicant is employed/contracted by a business, or in partnership, enter the name of the business you are employed by, affiliated with, contracted with, or in partnership with.  Proof of the EIN number (federal tax number) is REQUIRED.  Providers must attach a copy of their licensure/certification, as applicable.  The SSN is required for an individual and is confidential to be used only for the administration of the program.
PLEASE TYPE OR PRINT CLEARLY. Item#1: Individual providers must enter their last name, first name, and middle initial. All other applicants (e.g., a licensed business) must enter the complete business name as licensed/certified. Item#2: If the applicant is employed/contracted by a business, or in partnership, enter the name of the business you are employed by, affiliated with, contracted with, or in partnership with. Item#4: Proof of the EIN number (federal tax number) and the NPI number (national provider identificationif applicable) is REQUIRED. Item#5: Providers must attach a copy of the licensure/certification, as applicable. Item#6: The SSN is required for an individual/OWNER and is confidential to be used only for the administration for the program.
PLEASE TYPE OR PRINT CLEARLY. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED.

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