Common Contracts

Contract

Form and Agreement • October 5th, 2017

• Contract Type
  Form and Agreement
• Filed
  October 5th, 2017

COMMUNITY BASED ORGANIZATION PROGRAM REFERRAL REGISTRATION FORM AND AGREEMENT (“CBO AGREEMENT”) * indicates required field*COMMUNITY BASED ORGANIZATION (“CBO”) NAME: *CONTACT NAME: *CONTACT NAME FOR PAYMENT PURPOSES: *MAILING ADDRESS: *PHONE NUMBER: *EMAIL ADDRESS: WEBSITE: BUSINESS LICENSE #: *FEDERAL EMP. ID#: NOTE: CBO’s current W-9 must be submitted to Allied Universal *NON-PROFIT ORGANIZATION OR TAX EXEMPT  YES  NO If YES, please provide either a valid and current tax exemption certificate or direct pay certificate, authorized by the appropriate taxing authority with this completed form. *INDICATE YOUR TYPE OF SPECIAL ENTERPRISE Not-Applicable Faith-Based Organization (FBO) African American Business Enterprise (AABE) Veteran owned business enterprise (VBE) Service Disabled Veteran Owned Small Business (SDVOSB) Minority business enterprise (MBE) Small business enterprise, (SBE) Women-owned business enterprise (WBE) Disabled veteran business enterprise (DVBE) Disadvant