Vendor Name and Address |
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ADP Vendor Invoice |
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Vendor Information |
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ADP Vendor Registration Number |
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ADP Vendor Name |
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Invoice Information |
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ADP Claim Number |
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Vendor Invoice Number |
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Invoice Date (yyyy/mm/dd) |
_____/___/___ |
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Client Information |
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Client Health Number |
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Version: |
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Client Name (Last Name, First Name) |
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Client Address |
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Benefit Program |
Check one only: Ontario Works Program (OWP) Ontario Disability Support Program (ODSP) Assistance to Children with Severe Disabilities (ACSD) |
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Equipment Specifications |
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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
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Invoice Totals |
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Proof of Delivery |
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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.
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Client Signature |
Date of delivery (yyyy/mm/dd): _____/___/___ |
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