ADP PAGE 11 & 12 SIGNATURE

ADP Page 11-12

Applicant’s Consent and Signature

Applicant's Last Name

First Name

Health Number (10 Digits)

Version Code

Applicant Signature

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Date

Signing as

Applicant

Agent

First Name

Middle Initial

Last Name

Unit Number

Street Number

Street Name

City/Town

Province

Postal Code

Home Telephone Number

Business Telephone Number

Authorizer's Signature

Authorizer’s Last Name

Authorizer’s First Name

Telephone Number

Authorizer Registration Number

Authorizer Signature

Clear

Assessment Date

Vendor Representative Information

Vendor Business Name

ADP Vendor Registration Number

Vendor Representative (Last, First Name)

Position Title

Vendor Location

Business Telephone Number

Vendor Representative's Signature

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Date Signed

EMAIL 1

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EMAIL 2

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Hospital Beds

Medical Mattress

Bed Accessories

Powerchairs

ADP Approved

Funding Groups

Mobility Scooters

By Category

Funding Groups

Patient Lifts

Patient Lift Slings

Funding Programs

ADP PAGE 11 & 12 SIGNATURE

Applicant’s Consent and Signature

Authorizer's Signature

Vendor Representative Information

Hours of Operations

Hospital Beds

Medical Mattress

Bed Accessories

Powerchairs

ADP Approved

Funding Groups

Mobility Scooters

By Category

Funding Groups

Patient Lifts

Patient Lift Slings

Funding Programs

ADP PAGE 11 & 12 SIGNATURE

Applicant’s Consent and Signature

Authorizer's Signature

Vendor Representative Information

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