Form Dhcs 4468 - California Family Pact Provider Application - Health And Human Services Agency Page 8

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1. Legal name of provider (as listed with the IRS)
2. Business name, if different
3. Business telephone number
4. Business email address
5. Business facsimile number
Is this a fictitious business name?
If yes, list the fictitious business name
Effective Date
statement/permit number
Yes
No
6. Business address (number, street)
City
County
State
Nine-digit ZIP code
7. Pay-to-address (number, street,
City
County
State
Nine-digit ZIP code
P.O. Box number)
8. Mailing address (number, street,
City
County
State
Nine-digit ZIP code
P.O. Box number)
9. License number
License effective
License expiration
date
date
(attach a legible copy)
10. Taxpayer Identification Number (TIN issued by
11. Social Security Number. If sole proprietor
the IRS (attach a legible copy of the IRS form)
not using TIN, you must disclose this number.
12. Driver’s license or state-issued identification
13. Date of birth
number and state of issuance (attach a legible
copy)
14. Additional Service Site(s) Please attach a separate sheet of paper for any additional sites not
listed below.
Business name
NPI
Business
telephone number
Business address (number, street)
City
County
State Nine-digit ZIP code
Business name
NPI
Business
telephone number
Business address (number, street)
City
County
State Nine-digit ZIP code
7
Page 6 of
DHCS 4468 (4/17)

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