Representative Email Address definition

Representative Email Address. Enter the email address. PLEASE PRINT CLEARLY. This should be a business email address. This email address will be entered as part of your Submitter file profile. This email address will be used to contact someone from your company concerning the electronic file submission or allow you to submit HIPAA electronic claims.
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Representative Email Address. Enter the email address. PLEASE PRINT CLEARLY. This should be a business email address. This email address will be entered as part of your Submitter file profile. This email address will be used to send a confirmation to acknowledge the processing of the EDI AGREEMENT and confirm your submitter profile has been updated to allow you to send TEST NCPDP D.0 or 1.2 claims.
Sample 1

Examples of Representative Email Address in a sentence

  • Offeror’s Name: _ _ _ Address, City, State, and Zip Code:_ _ _ _ Phone Number: _ Fax Number: Printed Name and Title of Authorized Representative: Email Address: Signature of Authorized Representative Date: _ Exhibit GNew Jersey Business Compliance NEW JERSEY BUSINESS COMPLIANCE Suppliers intending to do business in the State of New Jersey must comply with policies and procedures required under New Jersey statues.

  • Vendor Name: Address, City, State, and Zip Code: Phone Number: Fax Number: Printed Name and Title of Authorized Representative: Email Address: Signature of Authorized Representative: Date: Form G – SB 9 Contractor Certification: Contractor EmployeesBackgroundTEX.

  • Your signature also certifies that no suspension or debarment is in place, which would preclude receiving a federally funded contract under the Federal OMB, A‐102, Common Rule ( .36) Vendor Name: Authorized Company Official’s Name: Title of Authorized Representative: Email Address: Signature of Authorized Company Official: Date: Form W-9 (Rev.

  • BUYER: [Print Restaurant(s) Now Owned by Buyer] [Print Name and Title of Buyer] [Email Address] [Cell Phone] [Address] [City] [State] [Zip Code] BY: [Authorized Signature of Buyer] [Date] BUYER’S REPRESENTATIVE: [Name and Title of Buyer’s Representative] [Email Address] [Cell Phone] [Address] [City] [State] [Zip Code] BY: [Buyer’s Representative Signature] [Date] Acknowledgement: BBG, Ltd.

  • Vendor Name: Address, City, State, and Zip Code: Phone Number: Fax Number: Printed Name and Title of Authorized Representative: Email Address: Signature of Authorized Representative: Date: FORM G – SB 9 CONTRACTOR CERTIFICATION: CONTRACTOR EMPLOYEESBackgroundTEX.

  • Supplier’s Name: Address, City, State, and Zip Code: Phone Number: Fax Number: Printed Name and Title of Authorized Representative: Email Address: Signature of Authorized Representative: Date: EDGAR CertificationsWhen an E&I Member seeks to procure goods and services using funds under a federal grant or contract (“federal funds"), specific federal laws, regulations, and requirements may apply in addition to those under state law.

  • Contractor’s Name/Company Name: Address, City, State, and Zip Code: Phone Number: Fax Number: Printed Name and Title of Authorized Representative: Email Address: Signature of Authorized Representative: Date: Neither my company nor an owner or principal of my company has been debarred, suspended or otherwise made ineligible for participation in Federal Assistance programs under Executive Order 12549, “Debarment and Suspension,” as described in the Federal Register and Rules and Regulations.

  • V endor’s Name: Address, City, State, and Zip Code: Phone Number: Fax Number: Printed Name and Title of Authorized Representative: Email Address: Signature of Authorized Representative: Date: EXHIBIT 2 HISD CERTIFICATE OF INTERESTED PARTIES – FORM 1295 Certificate of Interested Parties (Form 1295 – must be filled out electronically with the Texas Ethics Commission’s online filing application, printed out, signed, notarized, and attached to vendor’s response to this solicitation.

  • Vendor’s Name/Company Name: Address, City, State, and Zip Code: Phone Number: Fax Number: Printed Name and Title of Authorized Representative: Email Address: Signature of Authorized Representative:Date: Return to topATTACHMENT P: Required Contract Provisions for Non-Federal EntityContracts Under Federal Awards – Appendix II to 2 CFR Part 200 The following provisions are required and apply when federal funds are expended by Taylor County for any contract resulting from this procurement process.

  • The effective preservation of biological diversity was the responsibility not only of the national governments that were signatories of the Convention but also of regional and – especially - local authorities, the private sector, communities and non-governmental organizations, which had crucial roles to play in eradicating socio-economic, urban and cultural models that were characterized by destructive behaviour and in creating and mobilizing public awareness.

Related to Representative Email Address

  • Notification Email Address means the email address (if any) designated by Customer, via the user interface of the Processor Services or such other means provided by Google, to receive certain notifications from Google relating to these Data Processing Terms.

  • Residential address means the physical location where the student’s parents, legal guardians, persons having legal, lawful control of the student under order of a court, or persons standing in loco parentis reside. A student may use the residential address of a legal guardian, person having legal, lawful control of the student under order of a court, or person standing in loco parentis only if the student resides at the same residential address and if the guardianship or other legal authority is not granted solely for educational needs or school attendance purposes.

  • Street Address City: State: Zip: Code: Contact Person: Telephone Number: E-mail Address: Dates of Service: Value/Cost of Service: $ Brief Description of Service Provided: REFERENCE 3 Name of Firm:

  • supply address means the premises to which gas was, is or may be supplied under a contract.