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Add New Other Non-School Recipient

* = Required

Entity Details:

Official Name of Entity:
Geographically Located Within:
County(Code):
FEIN:
Open Date:
Email Address:
Phone Number:	- Phone Extension

Entity Physical Address Details:
Street:
Address Line2:
City:
State:
Zip: Zip Extension	-

Primary Contact Details:
Contact Type:
Honorific:
First Name:
Middle Initial:
Last Name:
Suffix:
Phone Number: Phone Extension	-
Fax Number: Fax Extension	-
Email:
Confirm Email:

Primary Contact Mailing Address Details:
Street:
Address Line2:
City:
State:
Zip: Zip Extension:	-