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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