Instructions are contained within each of these sections to assist an Authorized User in completing this work order. Most of these sections require the Authorized User to provide cost estimates for the services, equipment and software to be acquired from KMS. Section 1. Authorized User and Contractor Information Please provide the following contact information about the Authorized User and KMS. Instructions. Provide the Authorized User name and program name(s) as they appear on the Form EVTA-1, Program Plan Line a. Application(s). The Program #(s) are assigned by the EVTA and can be found in Part 3 of Form EVTA-1. Provide the DBA (doing business as) name, if different from the Authorized User name. Include DBA address if it is Line b. different from the Authorized User address. If multiple DBAs will be used, please indicate and such information will be obtained during implementation. Provide the Authorized mailing address. Line c. User’s To be supplied by the Authorized User, provide the name of the primary contact for this program and include their e-mail Line d. address, phone and fax numbers. Provide the Authorized customer service telephone number and website (and list the customer service website Line e. User’s address if it is different) Authorized User Tax ID Number (if multiple numbers are to be used, provide a list of all names and numbers). Also, Line f. submit a copy of the Authorized W9 to KMS if different from those previously provided. User’s Check if additional locations/merchant identification numbers are required. Provide a separate sheet with the information Line g. requested, or contact KMS who will supply a form for this information. To be supplied by KMS, provide the name of the KMS account management contact for this program and include their Line h. address and phone number. For Non-State Agency Authorized Users, supply financial statements or website where statements are located. Line i. a Authorized User Name Program Name(s) Program #(s) DBA name (if b different from □ Multiple DBAs to be used above) c Authorized User Address (street address, city, state, zip) d Authorized User E-Mail Contact Address Phone Number Fax # (include cell if applicable) e Authorized User Authorized Customer Service User Phone Number Website f Authorized User Additional Tax ID# Tax ID#
Instructions are contained within each of these sections to assist an Authorized User in completing this work order. Most of these sections require the Authorized User to provide cost estimates for the services, equipment and software to be acquired from KMS. Section 1. Authorized User and Contractor Information Instructions. Please provide the following contact information about the Authorized User and KMS. Line a. Provide the Authorized User name and program name(s) as they appear on the Form EVTA-1, Program Plan Application(s). The Program #(s) are assigned by the EVTA and can be found in Part 3 of Form EVTA-1. Line b. Provide the DBA (doing business as) name, if different from the Authorized User name. Include DBA address if it is different from the Authorized User address. If multiple DBAs will be used, please indicate and such information will be obtained during implementation. Line c. Provide the Authorized User’s mailing address. Line d. To be supplied by the Authorized User, provide the name of the primary contact for this program and include their e-mail address, phone and fax numbers. Line e. Provide the Authorized User’s customer service telephone number and website (and list the customer service website address if it is different) Line f. Authorized User Tax ID Number (if multiple numbers are to be used, provide a list of all names and numbers). Also, submit a copy of the Authorized User’s W9 to KMS if different from those previously provided. Line g. Check if additional locations/merchant identification numbers are required. Provide a separate sheet with the information requested, or contact KMS who will supply a form for this information. Line h. To be supplied by KMS, provide the name of the KMS account management contact for this program and include their address and phone number. Line i. For Non-State Agency Authorized Users, supply financial statements or website where statements are located. a Authorized User Name Program Name(s) Program #(s) b DBA name (if different from above) □ Multiple DBAs to be used c Authorized User Address (street address, city, state, zip) d Authorized User Contact E-Mail Address Phone Number (include cell if applicable) Fax # e Authorized User Customer Service Phone Number Authorized User Website f Authorized User Tax ID# Additional Tax ID#