<p> DMHAS Fee-For-Service Network Contract Enrollment Application FY 2013-14</p><p>AGENCY ADMINISTRATIVE INFORMATION CONTRACT APPLICATION SIGNATURE PAGE</p><p>AGENCY NAME: </p><p>ADMINISTRATIVE ADDRESS: </p><p>CITY: STATE: ZIP: - </p><p>COUNTY: </p><p>TELEPHONE NUMBER: ( ) ext </p><p>FAX NUMBER: ( ) ext </p><p>FEDERAL TAX ID #: (Will be confirmed upon submission of required contract application documents) </p><p>ADMINISTRATIVE CONTACT: </p><p>NAME: </p><p>TITLE: </p><p>EMAIL ADDRESS: </p><p>SIGN NAME: </p><p>PRINT NAME: </p><p>TITLE: </p><p>DATE: </p><p>Page 1 of 2</p><p>DMHAS FFS Enrollment materials are due by October 1st 5:00 pm Fall 2012 enrollment</p><p>DMHAS Fee-For-Service Network Contract Enrollment Application FY 2013-14 Mailing Information for submission of Contract Enrollment Application:</p><p>Overnight: New Jersey Division of Mental Health & Addiction Services 222 South Warren Street- 3rd floor Trenton, NJ 08611 Attention: Geralyn Molinari</p><p>Postal delivery: New Jersey Division of Mental Health & Addiction Services P.O. Box 362 Trenton, NJ 08625-0362 Attention: Geralyn Molinari</p><p>Page 2 of 2</p><p>DMHAS FFS Enrollment materials are due by October 1st 5:00 pm Fall 2012 enrollment</p>