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Get 2007 Application - Final Pdf.doc - State Ar

Ant award with any Arkansas State Agency. SOCIAL SECURITY NUMBER TAXPAYER ID #: ---- ---- FEDERAL ID NUMBER OR SUBCONTRACTOR: Yes ---- SUBCONTRACTOR NAME: No IS THIS FOR: Goods? TAXPAYER ID NAME: YOUR LAST NAME: FIRST NAME: Services? Both? M.I.: ADDRESS: CITY: STATE: ZIP CODE: --- COUNTRY: AS A CONDITION OF OBTAINING, EXTENDING, AMENDING, OR RENEWING A CONTRACT, LEASE, PURCHASE AGREEMENT, OR GRANT AWARD WITH ANY ARKANSAS STATE AGENCY, THE FOLLOWING INFORMATION MUST BE DISCL.

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