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 Client
Client will pickup
Client Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number
*
-
Area Code
Phone Number
Vendor Information
Vendor Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
OFFICE USE ONLY
Date Client Contacted
Elder Care Staff
Date Check Picked Up
Date Check Mailed
Signature of Client
Signature of Staff
Submit
Should be Empty: