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317/2010 <br />1.3 - CONTRACTOR INFORMATION SHEET <br />Request for Verification / Notification of Information Changes <br />Name of Business �t <br />or Individual: JIYAX 1 X40 f&fit/e <br />(List name as will appear on Invoice) <br />Owner's Name: d Allmt 40(dell <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 />Primary Contact: A/W ' 16a.)e Work Phone #: (74) <br />Cell Phone #: o L09 <br />" S" <br />Fax #: <br />Email Address: �1� Sa 0 C7 it/e/ <br />Secondary Work Phone #: ( 70� 1 <br />Contact: e� �3to �''��' <br />Cell Phone #: <br />Mailing Address: 4 3 0 0 rye IIAJ <br />Number Used To File Federal Income Tax: <br />Federal Tax ID: t10d0 _ 4 <br />Physical Address MUST BE CORRECT FOR 1099 PURPOSES <br />DUNS # (ARRA) <br />Taxing County: <br />(if NC) <br />Business & Individual Characteristics (Complete All): Number of Years: <br />Check ALL That Apply: ❑ NCDOT Certified DBE At this location y 4yrs <br />❑ Individual* ❑ Minority -Owned Bus (MBE) Under current ownership /management: yrs <br />❑ Sole Proprietorship* ❑ Women -Owned Business <br />❑ Federal Government Enterprise (WBE) <br />❑ State Government <br />❑ Local Government <br />❑ Partnership '°* <br />Ef Corporation (Check ALL that apply) ** <br />❑ Not For Profit <br />❑ Sub- Chapter S <br />❑ Medical / Health <br />* can be either Social Security Number or Federal EIN <br />* *Partnerships & Corporations must furnish Federal EIN <br />This information is true and accurate to the best of my knowledge and ability. <br />Typed Name of Person Completing this Form: a <br />Title: 1/ r© <br />53 <br />F -5 <br />. _ #attachment number_1 _. __ <br />Page 123 <br />