Asap Organization Enrollment And User Id Request Form printable pdf download

ASAP Organization Enrollment and User ID Request Form

Section I - Organization Information

Date: ___________________

Action: [ ] NEW ORGANIZATION

[ ] CHANGE EXISTING ORGANIZATIONAL DATA

ASAP ID: ______________________

Organization Name: ____________________________________________________________________ Employer Identification Number (EIN) (9digits):______________________________

Organization Short Name (10 characters maximum): ___________________________

DUNS Number (9+4 digits):_______________________________________________

Organization Type: [ ] State Agency

[ ] University

[ ] ITO

[ ] For-Profit

[ ] Non-Profit

User Type: [ ] Recipient Organization

[ ] Super User

[ ] EBT Processor

[ ] FRB LOC

[ ] Other ________________________

Mailing Address:

________________________________________________________________

Street Address:

_______________________________________________________

________________________________________________________________

_______________________________________________________

City, State, Zip:

________________________________________________________________

City, State, Zip:

_______________________________________________________

Primary Contact Name:

________________________________________________________________

Secondary Contact Name: _______________________________________________

Phone: ____________________________________

Fax: ____________________________________

Phone: ____________________________ Fax: _____________________________

E-Mail Address: _________________________________________________________________________ E-Mail Address: ________________________________________________________

Section II – Individual User Information

NAME

FUNCTIONS

Current Users

Include First, Middle Initial, and Last

E-MAIL

Only:

TELEPHONE

MAILING ADDRESS

Name. Each individual MUST sign in the

Payment

Inquiry Only

AMA

User’s Logon ID

(If different from above)

NUMBER

appropriate space on the reverse side.

Request

(PR1 or RC1)

(PR2)

[ ] Add [ ] Change [ ] Delete

Legend: Functions: A=Add, C=Change, D=Delete. If requesting AMA, an AMA Access Form is required.

Current Users Only: Indicate the existing individual’s logon ID in this column for any changes to a user’s functions or access.

Section III – Authorizing Official’s Signature

By signing this document, I certify that the individual(s) requiring access to ASAP and identified above have read and signed the “User Responsibility Statement” on the reverse

side of this document and that the organization will maintain the signed copy.

__________________________________________________________

______________________________________________________

Signature

Title

_____________________________________________________________________

___________________________________

__________________________

Name

Phone Number

Date

Form Date: 09/2008