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ARIZONA STATE PURCHASING COOPERATIVE AGREEMENT <br />Page 5 of 5 <br />ARIZONA STATE PUCHASING COOPERATIVE AGREEMENT <br />Updated <br />State Cooperative Member Contact Information <br />Name of Organization: <br />Name of Contact Person: Qualification: (Click the appropriate Box in either the Political <br />Subdivision or Non-Profit categories) <br />Political Subdivision: Non-Profit Organization: <br />Title of Contact Person:Federal <br />Agency/Gov’t <br />State <br />County <br />City/Town <br />Public School <br />Other <br />Educational <br />Institution <br />Tribal Nation <br />Fire District <br />Water District <br />Other: <br />____________ <br />Healthcare <br />Institution <br />Religous <br />Organization <br />Charity <br />Other: <br />_____________ <br />Telephone of Contact Person: <br />Telephone of Office: <br />E-mail address of Primary Contact Person: <br />E-mail Address of Secondary Contact: <br />(If possible, please provide a general email address that can be forwarded to the contact person and that will not change should <br />the contact person leave the organization. The person receiving email from the State Procurement Office at the address above <br />needs to be responsible to forward the information to other interested parties at your organization as needed.) <br />Physical Address: <br />Mailing Address (if different from the physical address): <br />Federal ID Tax Number: <br />*Non-profit entities must attach proof of non-profit status with the agreement <br />Please notify the State Procurement Office of any changes to this information. <br />Theresa Bauccio-Teschlog <br />Procurement Manager <br />425-257-8901 <br />tbauccio@everettwa.gov <br />x <br />x <br />425-257-8840 <br />2930 Wetmore Avenue, Everett, WA 98201 <br />PO Box 12130, Everett, WA 98206 <br />91-6001248 <br />City of Everett, Washington <br />bids@everettwa.gov