Field 2: BILLING SERVICE NAME If applicable, enter the name of the billing service that the provider is enrolled. with. If you are not using a billing service, leave this field blank. Field 3: DATE Enter the date the Certification Statement is submitted to the fiscal agent.
Gregory Jerome Coleman (born September 9, 1954 in Jacksonville, Florida) is a retired American football punter who had a 12-year career in the National Football League playing for the Cleveland Browns, the Minnesota Vikings, and the Washington Redskins. He attended Florida A&M University.
Mark Travis John Sanchez (born November 11, 1986) is an American football quarterback for the Chicago Bears of the National Football League (NFL). He was drafted by the New York Jets in the first round of the 2009 NFL Draft as the fifth overall pick. He played college football at the University of Southern California (USC).