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.
Roger Timothy Craig (born July 10, 1960) is a former American football running back in the National Football League (NFL). He played with San Francisco 49ers, Los Angeles Raiders and Minnesota Vikings. Craig went to four Pro Bowls and won three Super Bowls with the 49ers.