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Proposer: <br />11TRE <br />Name of Business <br />or Individual: <br />Owner's Name: <br />Primary Contact: <br />1.3 - CONTRACTOR INFORMATION SH <br />Request for Verification I Notification of Information C <br />(List name as will appear on I <br />W� <br />317/2010 <br />(Individuals: names as it appears on Social Security Card <br />Sole Proprietorships: Name as it appears on SS Card or EIN Notification <br />Partnerships and Corporations: Correct legal name of business) <br />Work Phone #: _ <br />Cell Phone #: _ <br />Fax #: _ <br />Email Address: _ <br />Secondary Contact: X: DW)ia �• �` n'�' Work Phone #: <br />Cell Phone #: <br />Mailing Address: 1 i f. �&LNumber Used To Fife <br />Federal Tax ID: <br />� MUST 15E CORRECT FC <br />Physical Address: '�, _ r � - - DUNS # (ARRA) <br />Taxing County: <br />(if NC) <br />Business & individual <br />Check ALL That A 1 <br />❑ Individual* <br />❑ Sole Proprietorship* <br />❑ Federal Government <br />❑ State Government <br />❑ Local Government <br />"haracteristics (Complete All): <br />❑ NCDOT Certified DBE <br />❑ Minority -Owned Bus (MBE) <br />QWbrnen -Owned Business <br />Enterprise (WBE) <br />used below <br />s ra et — � <br />r5['_G nnr <br />Income Tax: <br />.n4 <br />Number of Years: <br />At this location 1_ yrs <br />Under current ownership /management: yrs <br />WPartnership ** <br />❑ Corporation (Check ALL that apply) ** <br />❑ Not For Profit <br />❑ Sub- haptet S *can be either Social Securit4 Number or Federal EIN <br />Sub- <br />❑ C Health — 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: <br />Title: 1'7 t i 't v..t?_C?— es; <br />Signature: Date <br />ITRE 2 <br />F -5 <br />p2U /0 <br />3/19/2010 <br />Attachment number 2 <br />Page 184 <br />