DANE COUNTY RECERTIFICATION APPLICATION FOR CCS SERVICE PROVIDERS Revised: 6.14.18 APPLICATION SUMMARY ORGANIZATION LEGAL NAME MAILING ADDRESS If P.O. Box, include Street Address on second line LEGAL STATUS TELEPHONE Private, Non-Profit FAX NUMBER Private, For Profit NAME CHIEF ADMIN/ CONTACT INTERNET WEBSITE Federal EIN: (if applicable) DUNS Number: E-MAIL ADDRESS CCS CONTACT PHONE CCS CONTACT PERSON E-MAIL TITLE NUMBER FISCAL OR ACCOUNTING FIRM FISCAL CONTACT E-MAIL CONTACT PERSON TITLE NUMBER I hereby attest that all statements made in this application and any attachments are correct to the best of my knowledge and that I will comply with all laws, rules, and regulations governing Comprehensive Community Services for persons with mental disorders and substance-use disorders. I have reviewed . Signature of Legal Representative/Organization Title Head Printed Name Date
DANE COUNTY RECERTIFICATION APPLICATION FOR CCS SERVICE PROVIDERS Revised: 6.14.18 APPLICATION SUMMARY ORGANIZATION LEGAL NAME MAILING ADDRESS If P.O. Box, include Street Address on second line TELEPHONE LEGAL STATUS FAX NUMBER Private, Non-Profit Private, For Profit Federal EIN: DUNS Number: NAME CHIEF ADMIN/ CONTACT INTERNET WEBSITE (if applicable) E-MAIL ADDRESS CCS CONTACT PERSON CCS CONTACT TITLE PHONE NUMBER E-MAIL FISCAL OR ACCOUNTING FIRM CONTACT PERSON FISCAL CONTACT TITLE NUMBER E-MAIL I hereby attest that all statements made in this application and any attachments are correct to the best of my knowledge and that I will comply with all laws, rules, and regulations governing Comprehensive Community Services for persons with mental disorders and substance-use disorders. I have reviewed . Signature of Legal Representative/Organization Head Title Printed Name Date