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

TOWNSHIP OF WEST ORANGE Failure of the bidder/proposer to submit the required information is cause for automatic rejection of the bid or proposal Part I Check the box that represents the type of business organization: Sole Proprietorship (skip Parts II and III, sign and notarize at the end) Non-Profit Corporation (skip Parts II and III, sign and notarize at the end) Partnership Limited Partnership Limited Liability Partnership Limited Liability Company For-profit Corporation (including Subchapters C and S or Professional Corporation) Other (be specific): ______________________________________________ Part II I certify that the list below contains the names and addresses of all stockholders in the corporation who own 10 percent or more of its stock, of any class, or of all individual partners in the partnership who own a 10 percent or greater interest therein, or of all members in the limited liability company who own a 10 percent or greater interest therein, as the case may be. OR I certify that no one stockholder in the corporation owns 10 percent or more of its stock, of any class, or no individual partner in the partnership owns a 10 percent or greater interest therein, or that no member in the limited liability company owns a 10 percent or greater interest therein, as the case may be. Complete, sign and notarize the form below. (Please attach additional sheets if more space is needed): 23