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And Libraries Service Provider Annual Certification Form Please read instructions before completing. (To be completed by Service Provider) Block 1: Service Provider Information 1. Name of Service Provider 2. Service Provider Identification Number (SPIN) 3. Funding Year: July 1, through June 30, 4. Contact Name 5. Complete Mailing Address of Contact Person Street Address, P. O. Box or Route Number City State 6. Telephone Number with Area Code - -.

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