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Get and Sign Assumed Name Certificate 2012-2022 Form
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Section I: Institution Identifying Information
Exact Legal Name of Agency
Contact Person/Name & E-mail Address
Federal Employer Identification Number (FEIN):
NYS Vendor Identification Number:***
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Federal System for Award Management/SAM – Is your Agency Registered?
(Please note that your agency MUST be registered in SAM (& must maintain a CURRENT registration) in order
to be awarded federal funds.)
□ Yes, then...
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