Ashe Memorial Hospital, Inc



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|Contractor Name (Agency) |

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|Federal Tax ID/SSN (IF CONTRACTOR IS AN INDIVIDUAL) |

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|Contractor Street Address, City, State, ZIP |

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|Contractor P.O. Address (if applicable), City, State, ZIP |

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|Contractor Fax Number |

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|Contract Administrator’s Name and Title |

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|Contract Administrator’s Phone Number |

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|Contract Administrator’s E-Mail Address |

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|Contractor Signatory’s Name and Title (if different from Contract Administrator) |

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|Contractor Signatory’s Phone Number (if applicable) |

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|Contractor Signatory’ E-Mail Address (if applicable) |

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Agency’s fiscal year: through

Check one that applies to your organization:

University Non-Profit Public/Governmental

For-Profit Other

|Contractor’s DUNS#: | |

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|Contact Person for this application: | |

|Phone: |Email: |

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