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�ITRE <br />1.3 - CONTRACTOR INFORMATION SHEET <br />Request for Verification I Notification of Information Changes <br />Name of Business <br />or Individual: <br />Owner's Name: <br />(mitivlcuals: names as It appears on boaal Becurlty card <br />Sole Proprielorships: 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: <br />(70066-andV <br />Cell Phone #:o <br />a9- siS6 <br />Fax #: <br />36.8D3 L/ <br />Email Address:/LP9�%1aV6u <br />r <br />✓�• <br />( ) cars? <br />86edrIfti rte #: <br />7,1,1 3G• zo,7 <br />Contact:LT <br />CN/I /� Ton e5 <br />Cell Phone#: <br />(7N)�o!-79iiie- <br />Mailing Address: <br />63co AlC f/u f' 0 jlpasan Al/ <br />�/ y' <br />69 ,,,,//w ce /1'[. /Y ( Number Used To File <br />Federal Income Tax: 7¢I>y <br />Federal Tax ID: <br />a�taSa <br />np <br />;9L, - 0 " [ 7 / yp y <br />Physical Address: /�%a< r� lye . of/ MUST BE CORRECT FOR <br />1999 PURPOSES <br />DUNS #(ARRA) <br />Taxing County: <br />(II NC) <br />Business & Individual Characteristics (Complete All): <br />Number ofYears: <br />Check ALL ThatAonAr: NCDOT Certified DBE <br />At this bcationLL_yrs <br />Individual' Minority -Owned Bus (MBE) Under current ownership/management: _L yrs <br />❑ Sole Proprietorship' Women -Owned Business <br />❑ Federal Government Enterprise (WBE) <br />❑ State Government <br />❑ Local Government <br />❑ Partnership" <br />L✓ Corporation (Check ALL that apply)" <br />❑ ❑ Nat For Profit <br />❑ Sub-ChaplerS <br />` can be either Social Security Number or Federal EIN <br />❑ Medical /Health <br />"Partnerships & Corporations must furnish Federal EIN <br />50 <br />Attachment number 1 U <br />F-3 Page 168 <br />