QUIVISION CONSULTING, LLC

                                                                                                                 Washington, D.C

                                                                                                              Office: 202-596-6108

                                                                                                                Fax:  202-301-8524

                                                                                                Quivisionconsulting.US@gmail.com

                                                                                            https://quivisionconsultin.wixsite.com/qmlj

 

                                                                                         GRANTS VENDOR REQUEST PROFILE FORM

 

IT IS CRITICAL TO LME/MCO THAT YOU COMPLETE ALL DATA – PLEASE PRINT OR TYPE

(A W-9 FORM & EFT Authorization Form IS REQUIRED AND MUST BE SUBMITTED WITH THIS FORM)

 

 

Legal Name (As registered with the Secretary of State):  Click here to enter text.

 

Doing Business As:  Click here to enter text.

 

Corporate Headquarters Address: Click here to enter text.

 

Mailing Address: Click here to enter text.

 

Billing Address: Click here to enter text.

 

Provider Website Address (URL): Click here to enter text.

 

Service Site(s) (address other than Corporate Headquarters):           

 

1. Click here to enter text.                         2) Click here to enter text.

 

(Use additional sheet if needed)

 

Telephone:  Click here to enter text.                              Fax:  Click here to enter text.     

 

Emergency Phone Number: Click here to enter text.     Federal Tax ID No:  Click here to enter text.

 

Do you require a 1099?  Yes      No         

 

In what City and State is your agency licensed? Click here to enter text.

If licensed in the U.S., indicate County (for tax purposes) Click here to enter text.

 

Business Type (check all applicable boxes):

 C-Corp.   S-Corp.  LLC   General Partnership   Sole Proprietorship   Limited Partnership    

                                   

 PC   LLP   Governmental Agency   Profit   Non-Profit 

 

Is your agency a large business?  Yes      No       is agency a small business?  Yes      No

 

Is your agency 51 percent or more owned and operated by a woman?  Yes      No

If yes, with what governmental agencies are you certified?  Click here to enter text.

 

Is your agency 51 percent or more owned and operated by a minority?  Yes      No

If yes, with what governmental agencies are you certified?  Click here to enter text.

Identify appropriate minority group:

 Black American  Native American   Hispanic   Asian/Pacific  Asian Indian     

 

 

 

 

 

 

 

VENDOR PROFILE FORM                                                                                PAGE 2

 

Other Contracting Entities       Click here to enter text.             Click here to enter text.

 

                                                Click here to enter text.             Click here to enter text.

 

 

Executive Director (Name):                  Phone:  (           )          -                       Cell:      (           )           -

                                                            E-mail Address:             Click here to enter text.

 

 

Program Director (Name):                    Phone:  (           )           -                       Cell:      (           )           -

                                                            E-mail Address:             Click here to enter text.

 

 

Accounting Contact (Name):                Phone:  (           )           -                       Cell:      (           )           -

                                                            E-mail Address:             Click here to enter text.

 

 

 

(Use additional sheet if needed)

 

Office Hours:

 

Monday: Click here to enter text.           Tuesday: Click here to enter text.

Wednesday: Click here to enter text.     Thursday: Click here to enter text.

Friday: Click here to enter text.              Saturday: Click here to enter text.                    

Sunday: Click here to enter text.

 

List names of those with authority to sign billings and receive payments, including name, title, e-mail, and telephone number:

 

Name:                                                  Title:                                         Phone:  (            )           -

                                                            E-Mail Address:

 

Name:                                                  Title:                                         Phone:  (            )           -

                                                            E-Mail Address:

 

Name:                                                  Title:                                         Phone:  (            )           -

                                                            E-Mail Address:

 

 

Signature: _________________________________ Title: _________________________________

 

 

Print name: ____________________________ Date: _________________________________

 

 

 

Return to Quivision Consulting, LLC. Washington, DC Office: 202-596-6108  Fax: 202-301-8524

Quivisionconsulting.US@gmail.com