Section 5; View 5.15; Version 1.1
Questionnaire Response -- Organizational Information
Questionnaire forms for organizations that want to be included
Organizational Information
from View 5.15
3. Legal name of Company –Summit Achievement of Stow, Inc.
4. Legal Address:
69 Deer Hill Road
Stow, Maine 04037
207.697.2020 Fax:
207.697.2021
Email: admissions@summitachievement.com
12. List any DBA names (“Doing
business as”), that is, other names by which this company is known.
Summit Achievement
13. State (or other jurisdiction) in which you are incorporated:
Maine
14. Are you a publicly held corporation?
No
15. Identify all persons and/or legal entities holding more than 5% interest, preferably in order according to the size of holding starting from the greatest to the least. List the investors with the common name by which the investor is best known.
Nicholas Will White, Clinical Director
Adam Tsapis, Director of Admissions
Christopher Mays, Executive Director
17. Who are the members of your governing board?
18. Is your organization managed by a contract manager or management company?
If “yes” please identify the contractor/company:
No
29. Please identify your Chief Executive
Officer (whether or not that is the title you use). We refer to the most
senior person actually functioning as a full time manager or executive,
reporting to the board or to investors.
Christopher Mays
Executive Director
69 Deer Hill Road
Stow, Maine 04037
Telephone: 207.697.2020
Fax:
207.697.2021
Email: chris@summitachievement.com
30. Chief Operating Officer
Margaret Lannon, Program Director
Address: Same as above
Email: margie@summitachievement.com
31. Please identify your Chief Financial Officer
None
32. If you are a direct service provider, please identify your
principal contact person regarding
new admissions or enrollments or
other delivery of service.
This is the person our readers should contact if they want to
purchase services from you. If you are not a direct service provider, enter
“none.”
Adam Tsapis, Admissions Director
Address: Same as above
Email: Admissions@summitachievement.com
33. Person to Contact on general business matters:
Christopher Mays, Executive Director
Address: Same as above
Email: chris@summitachievement.com
34. Please attach an organization chart of your organization
Dependence / Independence
The following responses in Section 1 of the questionnaire suggest that Summit Achievement is a totally independent entity, not controlled not owning or controlling or affiliated with any other organization of interest to FamilyLight sm.
1.3 ___Yes X No Are you a Parent Organization (holding company, umbrella organization)? If you check “yes,” you have an “A number” of 3.
1.5 X Yes ___ No Is your organization is completely independent? If you check “yes,” you have an “A number” of 5. You are independent for our purposes if you are not controlled or affiliated with another organization
35. Name and contact information of person responsible for accuracy of questionnaire:
Name: Christopher Mays, Executive Director
Address: Above
Questionnaire forms for organizations that want to be included