Entity Code: __________
Current Entity Name: ____________________________________________________
Current Entity Address: __________________________________________________
Current Entity Telephone: ________________________________________________
Current Entity Fax: _____________________________________________________
Current Entity Email: ____________________________________________________
Current Entity Contact Name: _____________________________________________
Current Entity Contact Address: ___________________________________________
Current Entity Contact Pager: _____________________________________________
Current Entity Contact Mobil: _____________________________________________
Current Entity Contact E-mail: ____________________________________________
Current Entity Officers, Directors, General Partners, Members or Managers (with title):
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
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