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ITRIE <br />1.3 - CONTRACTOR INFORMATION SHEET <br />Request for Verification f Notification of Information Changes <br />Name of Business <br />or Individual: M A <br />Owner's Name <br />Primary Contact: <br />Secondary <br />Contact: <br />(List name as w0l appear on Invoice) <br />(Individuals: names as it appears on Social Security Card <br />Sole Proprietorships: Name as it appears on SS Card or EIN Notification as used below <br />Partnerships and Corporations: Correct legal name of business) <br />G 1e1Nr\ n ee <br />Mailing Address: (,;5tv tyc 4,,.L.A" 4 <br />Physical Address: j Nr l i , yjq <br />Taxing County: <br />(if NC) bdrt u 4 <br />Work Phone #: (2cr -I) 4346 -21724 _ <br />Cell Phone #: (col) 3051 - <br />Fax #- (`7©51) "Lk 3b -2034 <br />Email Address: rnar krvwt%l 6 I rwax ;b- icrs+V - 64 . C on" <br />Work Phone #: <br />( �l3b -2v2�F <br />Cell Phone #: ( - 70) <br />Number Used To File Federal income Tax: <br />Federal Tax ID: 3 V _ 1341 91 9 L. <br />MUST BE CORRECT FOR 1099 PURPOSES J <br />auNS # (ARRA) <br />Business & Individual Characteristics (Complete All): Number of Years: <br />Check ALL That Apply: ❑ NCDOT Certified DBE At this location '(U yrs <br />❑ Individual* ❑' Minority -Owned Bus (MBE) Undercurrent ownership /management, yrs <br />❑ Sole Proprietorship* ❑ Women -Owned Business <br />❑ Federal Government Enterprise (WBE) <br />❑ State Government <br />❑ Local Government <br />❑ Partnership ** <br />RCorporation (Check ALL that apply) ** <br />❑ Not For Profit <br />❑ Sub- Chapter S <br />❑ 'Medical i Health <br />* can be either Social Security Number or Federal EIN <br />* *Partnerships & Corporations must furnish Federal EIN <br />50 <br />Attachment number 1 <br />F -5 Page 172 <br />