Doing Business As Name (DBA) or Parent Organization Indicate if different from Legal Name above a copy of Assumed Name Certificate Attach If an Applicant has a Parent Organization, attach a copy of the agreement between the Applicant and the Parent Organization Mailing Address - If different from Office Address above Applicant: Parent Organization:_ Federal ID Number If different from Social Security Number - If applying as – Vendor ID Individual/Sole Proprietor Applicant: Parent Organization: Name of Person Authorized to Title Phone Number: Sign Contract Email: Name of Person Responsible for Title Phone Number: Billing Email: Type of Applicant Check appropriate box(es) and attach documentation as – indicated Are you applying to provide services to DFPS? Yes No Governmental Entity Do you have taxing authority? Yes No Private Corporation State of Incorporation: For Profit Charter Number: Non-Profit Attach a copy of Certificate of Incorporation Limited Liability Company (LLC) Attach a copy of the Articles of Incorporation
Doing Business As Name (DBA) or Parent Organization Indicate if different from Legal Name above Attach a copy of Assumed Name Certificate If an Applicant has a Parent Organization, attach a copy of the agreement between the Applicant and the Parent Organization Mailing Address - If different from Office Address above Applicant: Parent Organization:_ Federal ID Number – If different from Vendor ID Applicant: Parent Organization: Social Security Number - If applying as Individual/Sole Proprietor Name of Person Authorized to Sign Contract Title Phone Number: Email: Name of Person Responsible for Billing Title Phone Number: Email: Type of Applicant – Check appropriate box(es) and attach documentation as indicated Are you applying to provide services to DFPS? Yes No Governmental Entity Do you have taxing authority? Yes No Private Corporation For Profit Non-Profit State of Incorporation: Charter Number: Attach a copy of Certificate of Incorporation Limited Liability Company (LLC) Attach a copy of the Articles of Incorporation
6-1-CPA-Open-Enrollment-Application-Attachments-Required-Forms.docx