Ashe Memorial Hospital, Inc

Contractor Name (Agency)

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

Contractor Street Address, City, State, ZIP

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

Contractor Fax Number

Contract Administrator’s Name and Title

Contract Administrator’s Phone Number

Contract Administrator’s E-Mail Address

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

Contractor Signatory’s Phone Number (if applicable)

Contractor Signatory’ E-Mail Address (if applicable)

Agency’s fiscal year: through

Check one that applies to your organization: University Non-Profit Public/Governmental For-Profit Other

Contractor’s DUNS#:

Contact Person for this application: Phone: Email: