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.
Willie Thrower was a back-up quarterback who saw some action in the 1950s for the Chicago Bears. In 1954, running back Joe Perry of the San Francisco 49ers became the first black player to be recognized as NFL Most Valuable Player, when United Press International named him pro football's player of the year.