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: ___________________________________________________________ Print Name of Contact Person: ______________________________________________________ Print Correspondence Address (including zip code): _____________________________________ _____________________________________ _____________________________________ Purchase Order Address (including zip code): _____________________________________ _____________________________________ _____________________________________ Payment Address (including zip code): _____________________________________ _____________________________________ _____________________________________ Telephone Number: ___________________________ Fax Number: _________________________________ E-mail Address _______________________________ Employer I.D. or S.S. # _________________________