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: 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: 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 Home Health Care Agency Contract Signature Page The Office of Management and Enterprise Services Employees Group Insurance Division (EGID), and the facility incorporated by reference the terms and conditions of the Network Facility Contract into this signature page and acknowledge 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: FOR EGID: Legal Name of Owner (Typed or Printed) Xxxx X. Xxxx Deputy Administrator Employees Group Ins...
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
Name of Physician or Employer: HBTF Business ID Address: City Province Postal Code Fax Number: Area Code Number Area Code Number Applicant/Physician Member’s Signature mm dd yyyy 08/24 Health Benefits Trust Fund (HBTF) Plan Print clearly, in black or blue ink, and complete both pages of this form.
Telephone Number 000-000-0000 Fax Number: 000-000-0000 The Director, Wastes and Decommissioning Division (a position currently held by Xxxxxx Xxxxx) for matters related to the undertakings of the Arrangement.
Telephone Number: 000-000-0000 Fax Number: 000-000-0000 The Director, Regulatory Affairs & Environmental Assessment (a position currently held by Xxxxx Xxxxxxx) for matters related to the undertakings of this Arrangement.
Telephone Number: 000-000-0000 Fax Number: 000-000-0000 For the purposes of the Arrangement, the NWMO shall be represented by: The VP, Site Selection (a position currently held by Xxxxxx Xxx Xxxxxxxxx) for Senior Management Level matters.
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).
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 0000 Attention: Xx Xxxxx Xxxx/ Xx Xxx Xxxxx Xxxx By: /s/ Xxxxx Xxxx ----------------------------- Name: Xxxxx Xxxx ----------------------------- Title: Managing Director ----------------------------- OVERSEAS UNION BANK LIMITED 0, Xxxxxxx Xxxxx, 00xx Xxxxx, XXX Xxxxxx, Xxxxxxxxx 000000. Fax Number: 000 0000 Attention: Xx Xxxx Soo Suang/Xx Xxxxx Xx By: /s/ Mr Wee Joo Yeow ------------------------ Name: Mr Wee Joo Yeow ------------------------ Title: Executive Vice President ------------------------ SUMITOMO MITSUI BANKING CORPORATION, SINGAPORE BRANCH 0 Xxxxxxx Xxxxxx #00-00 Xxxxxxxxxx Xxxxx Xxxxxxxxx 000000 Fax Number: 000 0000 Attention: Xx Xxxx Xxxxxx/Xx Xxxxxx Tan By: /s/ Xxxxxxxxxx Xxxx ------------------------ Name: Xxxxxxxxxx Xxxx ------------------------ Title: Joint General Manager ------------------------ Guarantor Banks --------------- ABN AMRO BANK N.V., SINGAPORE BRANCH 00, Xxxxxx Xxxxxx, 0xx Xxxxx, Xxxxxxxxx 000000.
Fax Number. 000-000-0000
Fax Number. 536 7816 Telex number : RS 24396 Attention : Ms Sxxxx Xxx / Ms Pxxxxxxx Xxx
Fax Number. 293 0000 Xxxex Number: RS 21445 BAYSIN Attention: Mr Nx Xxxxx Xxx By: /s/ Ng Cxxxx Xxx By: /s/ Lum Xxx Xxx ------------------------- -------------------------------- Name: Ng Cxxxx Xxx Name: Lum Xxx Xxx ----------------------- ------------------------------- Title: Vice President Title: Assistant Vice President ---------------------- ----------------------------- CITIBANK, N.A., SINGAPORE BRANCH 5, Sxxxxxx Xxx, #00-00, XXX Xxxxxxxx, Xxxxxxxxx 000000. Fax Number: 225 0000 Xxxex Number: RS 24584 CITBANK Attention: Mr Bxxx Xxxx/Mr Lxx Xxxex Xxxx By: /s/ Bill Xxxx ------------------------- Name: Bill Xxxx ----------------------- Title: Vice President ---------------------- 70 74 OVERSEAS UNION BANK LIMITED 1, Rxxxxxx Xxxxx, 00xx Xxxxx, XXX Xxxxxx, Xxxxxxxxx 000000.