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ASAP.GOV Participation Request <br />AGENCY INFORMATION (Return this information to the address or FAX number below) <br />Bureau of Land Management <br />National Business Center <br />Denver Federal Center, Building 50 <br />P.O. Box 25047, BC – 620 <br />Denver, Colorado 80225 -0047 <br />FAX 303 - 236 -6599 <br />CONTACT PERSON NAME: DIANA MEDINA 303 - 236 -3332 or LORI ESQUIBLE 303 - 236 -6330 <br />ARE YOU A CURRENT ASAP RECIPIENT ID NUMBER:_ _ _ _ <br />BLM ASAP PARTICIPANT: ASAP PAYMENT REQUESTOR ID NUMBE <br />YES ❑ NO ❑ R <br />— — — — If Y do not fill out the bo ttom half of this form — — <br />IN ORDER FOR US TO PROCESS YOUR REQUEST EVERY PORTION OF THIS FORM WITH AN <br />ASTERISK ( *) MUST BE COMPLETELY FILLED IN. <br />Please print clearly <br />ENTER THE FOLLOWING: <br />Recipient Organization Name: <br />* DUNS: <br />* EIN: <br />Organization Type: <br />First Name: <br />Middle Initial: <br />* Last Name: <br />e.g., Jr, III) <br />Title: <br />* Organization Name: <br />Email: <br />Mailing Address 1: <br />Mailing Address 2: <br />U.S. Address <br />* U.S. City: <br />* U.S. State: <br />* U.S. Zip: <br />* U.S. Phone: <br />Page 5 of 5 <br />