Community Rehabilitation Program Application Form - Utah State Office Of Rehabilitation Page 5
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12UTAH STATE OFFICE OF REHABILITATION
1595 West 500 South / Salt Lake City, Utah 84104 / (801) 887-9500
FAX (801) 974-5477
Darin Brush, Executive Director
VENDOR INFORMATION FORM
Check one
Name change
1-Corporation
2-Medical Provider (all types)
Number change
3-Proprietorship/individual
4-Partnership
New
5-Government-Exempt
We are required by Federal law to report to the Internal Revenue Service any payments made
during each year. For this reason, we must be furnished with your Federal Tax Identification
Number. This will either be an employer identification number or a social security number and will
ensure remittance of our payment to you.
If you do not have a number or do not know your number, you may obtain an application for a
number from any local office of the Department of Finance.
Please fill in the form below and return it to the address above.
1.
Enter the Federal Tax I.D.
Number in this box (9 digit number)
2.
Please print or type:
a. The exact name of record for this
Federal Tax I.D. Number
b. The mailing address
3. Person in charge (print or type)
Signature of Vendor
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