ࡱ> 685 6bjbjWW -*== +8T `L4qssssss$&t(((|q(q((:<9OxϺ% ]0/ L"L9L9$"(LL :  EXHIBIT B STANDARD OFFER PROVIDER INFORMATION Page 1 of 2 Failure to fill out this form completely will render the T&D unable to provide services for the Provider. The Provider shall submit revisions to this document within 5 working days of any changes to the information herein. General Information for Licensed Provider: Provider Name___________________________________________________________ Corporate Address________________________________________________________ Dun & Bradstreet number___________________________________________________ Date of MPUC License_____________________________________________________ Business contact___________________________________________________________ Title_______________________________________________________________ Phone number_________________________________________ Facsimile number______________________________________ E-mail address________________________________________ Technical EDI contact_______________________________________________________ Title________________________________________________ Phone number________________________________________ Facsimile number_____________________________________ E-mail address_______________________________________ Authorized Signature:_________________________________________ Title:____________________________________ Date:____________________________________ Complete one form for each Doing Business As entity of the Provider. Doing Business As: __________________________________________________________ DBA Contact _____________________________________________________ Title ___________________________________________ Phone number ____________________ Fax number __________________ E-mail address _____________________________________________________ NMISA Company ID# ___________________________ Duns+4 ____________________ NMISA Load Asset Account # ____________________ Effective Date ________________ Value Added Network (VAN) Service _____________________________________________ Phone number ________________________________ EDI Trading Partner ID ________________________________ Attach VAN transmission schedule (In-bound & Out-bound). Banking Information Bank name _________________________________________________________ Bank phone _______________________________________ Routing & transit number (ABA) ______________________ Bank account number _______________________________ Federal tax id ______________________________________ Consolidated Utility Billing Service ( Yes ( No Customer account number format _______________________________________ Company name for bill print _____________________________________________ Customer service phone number for bill print _______________________________ Business hours for bill print ______________________________________________ Participate in T&D budget plans? ___________ Types of Rate Structures offered: ( Flat ( Blocked ( TOU ( seasonal Types of determinants used: ( kWh ( kWd ( kVard ( kVarh Attach rate descriptions. 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