NOSA - Northwest Ohio Scrip Association

Untitled Document

Scrip, what is it and Scrip Programs, what are they?

NOSA, WTPSPA, Scrip2000 and iScrip: Who we are and What we do!

Register With NOSA Thank you for your interest in NOSA. To register please
complete the form below. You may also download the Enrollment Application form and NOSA ACH Form and fax it to (419) 720-2939 or mail it to the NOSA office address of 4435 Nantuckett Dr., Toledo, OH 43623-3113.

Registration Form

Organization Name (participant)

Contact Name

Email Address

City

State

Zip Code

Organization Phone (with area code)

Organization Fax (with area code)

Contact Phone (with area code)

Tax ID #

Bank Routing # for ACH

Bank Account # for ACH

Shipping Adress (if different from above)

Street
City
State
Zip

THE PARTICIPANT HAS READ, DOES UNDERSTAND AND WILL ABIDE BY THE GENERAL POLICIES OF NOSA. THE PARTICIPANT FURTHER UNDERSTANDS THAT E-MAIL IS THE OFFICIAL COMMUNITCATION METHOD OF THE NOSA AND THAT NOTICES, PROCEDURES, POLICIES AND DATES WILL BE DISTRIBUTED FROM THE E-MAIL ADDRESS nwoscrip@yahoo.com. THE PARTICIPANT ALSO UNDERSTAND THAT BY REGISTERING THROUGH THE USE OF THIS FORM CONSTITUTES A DIGITAL SIGNATURE ON ITS PART.