Elder Care Vendor Check Agreement

Elder Care Vendor Check Agreement

The Elder Care Program of the Cheyenne and Arapaho Tribes, prefers to mail vendor checks directly to the vendor. However, in an effort to accommodate certain request this form can be utilized for vendor check to be mailed or picked up by client
Elder Care will complete the following:*

Mail to ClientClient will pickup
Client Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Area CodePhone Number
Vendor Information
Vendor Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
OFFICE USE ONLY
Date Client Contacted
Elder Care Staff
Date Check Picked Up
Date Check Mailed
Signature of Client

Clear
Signature of Staff

Clear
Should be Empty:

Client Information