VENDOR NAME AND ADDRESS ADP VENDOR INVOICE

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Vendor Name and Address

ADP Vendor Invoice

Vendor Information

ADP Vendor Registration Number


ADP Vendor Name


Invoice Information

ADP Claim Number


Vendor Invoice Number


Invoice Date (yyyy/mm/dd)

_____/___/___

Client Information

Client Health Number


Version:


Client Name (Last Name, First Name)


Client Address


Benefit Program

Check one only:

Ontario Works Program (OWP) Ontario Disability Support Program (ODSP)

Assistance to Children with Severe Disabilities (ACSD)

Equipment Specifications

Device Placement

(Left, Right, N/A)

ADP Catalogue Number

Description of Item

(Make & Model)

Serial Number

Quantity

Unit Price

Total Price

ADP Portion

Client Portion























Invoice Totals




Proof of Delivery

I hereby confirm that I have received the equipment described above and that I have received a fully itemized invoice from the vendor for the devices described above.


Client Signature

Date of delivery (yyyy/mm/dd): _____/___/___

Ministry of Health and Long-Term Care

Financial Management Branch
49 Place d'Armes, 2nd Floor
Kingston, ON,
K7L 5J3


7 MASTER VENDOR AGREEMENT AGREEMENT MADE THIS DAY
AC 3290S (REV 913) NYS VENDOR ID 000000000 NEW
AC 3291S (412) NYS VENDOR ID 000000000 NEW YORK


Tags: vendor name, the vendor, vendor, address, invoice