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Organization Fact Sheet

If you would rather print out the fact sheet and mail it in, click here to download the PDF version.

Please select the office to which you want to send this form:

1. Name of organization:
2. Mailing address:
City, state, zip:    
3. Web-site address: http://
4. Phone: Fax:
5. Executive director:
  Phone:
  Email:
6. President:
  Phone:
  Email:
7. No. of years in business:
  Tax ID no.:
7a. Business classification: Ownership:  Private   Public
Status:  For-profit   Not-for-profit
8. Do you require prior authorization for services?
Yes   No      If "yes" please explain:
9. Billing address:
(if different from above)
City, state, zip:    
10. Accounts payable contact:
  Title:
  Phone: Fax:
  Email:
 

List any previous addresses or legal names of business:

OSHA Information (Rhode Island organizations only must complete this section)

Please list the number of organization injuries for the past two full years:
Year    Number of Injuries
Year    Number of Injuries
NOTE: This information is required by ARBOR's Workers Compensation carrier

Credit Information

Bank:
Account Number:
Contact at bank:
Phone:

List 2 current business references:

Name: Phone:

Name: Phone: