Form 18 One Time Query for an Organization

Entity: TEST ENTITY (FAIRFAX, VA) | User: stateUser

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QUERY INPUT
To submit a query, enter all known subject data.
OMB # 0915-0239 expiration date 05/31/14
OMB # 0915-0126 expiration date 12/31/13
OMB # 0915-0331 expiration date 12/31/13
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. The OMB
control numbers for this project are 0915-0239, 0915-0126 and 0915-0331. Public reporting burden for
this collection of information is estimated to average 5 minutes to complete this form, including the time
for reviewing instructions, searching existing data sources, and completing and reviewing the collection
of information. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600
Fishers Lane, Room 14-22, Rockville, Maryland, 20857.

SUBJECT INFORMATION
Organization Information
Organization Name

Add another name used

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for information on filling out non-U.S. and military addresses.

Address
Street Address:
Address Line 2:
City:
State:

CHOOSE ONE FROM LIST

ZIP Code:

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-

Country:
(if U.S., leave blank)

Type
Organization Type:

CHOOSE ONE FROM LIST

Federal Employer Identification Numbers (FEIN)
Add another FEIN

Social Security Numbers (SSN)

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Add another SSN

Individual Taxpayer Identification Numbers (ITIN)
Add another ITIN

Drug Enforcement Administration (DEA) Numbers
Add another DEA Number

Clinical Laboratory Improvement Act (CLIA) Numbers
Add another CLIA Number

Federal Food and Drug Administration (FDA) Numbers
Add another FDA Number

National Provider Identifiers (NPI)
Add another NPI

Medicare Provider/Supplier Numbers
Add another Medicare Provider/Supplier Number

Organization State Licensure Information
(If no State License, check the 'No License' box.)
State License
Number:
State of Licensure:
Add another License

OR
CHOOSE ONE FROM LIST



 No
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License

 Check this box if you wish to store this subject in your subject database for use in
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future queries and/or reports. Duplicate entries in your subject database may result in
duplicate queries.

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