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ACS Trauma Quality Programs - New Site Application

Facility Information

Thank you for your interest in the ACS Trauma Quality Programs. Please complete the information below about your site to begin your application.

Upon submission of your application, our staff will review and contact you with next steps regarding enrollment for your selected Trauma Quality Program. If you have any questions, please contact Trauma Quality Program staff at traumaquality@facs.org.

Please note:

· Federal Employer Identification Number: asks for your facility's unique 9-digit number assigned by the Internal Revenue Service (IRS) to all businesses operation in the United States

· Tax ID Number if Outside USA: should be completed by international facilities only and asks for their facility's national identification number

Site Name:

Site Address:

Country:

City:

State:

ZIP:

Web Site:

Phone: (Country Code/Area Code/Number)

Ext:

Fax: (Area Code/Number)

Site Email:

FEIN:

NPI:

AHA Number: