1. # | 2. Contract Review Certification Package No. | 3. Name of Contractor/ Subcontractor | 4. Street Address | 5. City | 6. State | 7. Zip Code | 8. EIN # | 9. | 10. Service Type | 11. Contract Amount (Title II only) | 12. Minority Provider | ||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Yes | No | Yes | No | ||||||||||
| TOTAL FOR ALL CONTRACTS AWARDED | |||||||||||||