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X ID or SSN Save As * Name of Governing Body or Management Organization Mailing Address (Street) (City) (State) (Zip) (County) Service Address (Street) (City) (State) (Zip) (County) (If different than mailing address) Applicant ( owner or executive director) Telephone number ( Type of Service to be Provided ) Facility Capacity Identification of the type of consultants, subcontractors and community resources to be used by the vendor as part of its service CERTIFICATION I h.

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