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)
	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:

Credit Information

List 2 current business references:

Name: Phone: