318-22 Exhibit A-Coronis Health for Emergency Transport Third Party Billing - 2022.pdf

TOWNSHIP OF WEST ORANGE VENDOR INFORMATION In order to assure that all future correspondence is directed to the correct address, assure proper ordering, expedite future Payments, and in accord with I.R.S. regulations, the following information must be provided with this bid. Name of Business: Ca cont, & haLth, LEM LE Print Name of Contact Person: VEZ: wily LE. o* Print Correspondence Address (including zip code): 2 Late Phicth Uy (F Lea hl wt 127 TE Purchase Order Address (including zip code): Payment Address (including zip code): Telephone Number: 3 od ~_F 72 “2 7 Fax Number: 7 F.2-~ F8B-OP DS E-mail Address Ay Coron relballl, eCoset SA-/ESDVYOT Employer |.D. or S.S. #