VENDOR REGISTRATION FORM
Office of Services to the Aging

Select Agency: Status of Request:
Resource Name: Request Date:
Mailing Address: City:
Zip Code: Phone Number:
Fax Number: Toll Free:
Federal I.D. #: Director Name:
Email Address: Agency type:
Organizational Type Site Name:
Contact Name: Contact Phone Number:
AIS Application Status: Stop Date:
Cluster 1 Services Cluster 2 Services Cluster 3 Services
Adult Day Care Asst. Transp./Excort Serv Transportation Hearing Impaired
Care Management Congregate Meal Nutrition Information Education
Case Coordination/Support Congregate meals - USDA Info/Referral Guardian
Chore Service Nutrition Counseling Outreach Pysical Fitness
Home Delivered Meals-Col Pension Counseling Home Repair
HDM-Hot Elder Abuse Library Services
HDM-Liquid Vision Service Counseling
Home Health Aide Financial Mgt. Dental Service
Homemaker Health Screening Other
Personal Care Home Injury Contr. Legal Assistance
Respite - In Home Benefits Counseling Medication Mgt.
Respite - Out of Home Friendly Telephone Reassurance Disease Prevent
Respite - Specialized Ombudsman
Respite - Volunteer Diasaster Advocy Outreach Personal Emerg.
Sr. Ctr. Operation Sr. Ctr. Staffing
Notes:
Counties Served
Alcona Alger Allegan Alpena
Antrim Arenac Baraga Barry
Bay Benzie Berrien Branch
Calhoun Cass Charlevoix Cheboygan
Chippewa Clare Clinton Crawford
Delta Dickinson Eaton Emmet
Genessee Gladwin Gogebic Gr. Traverse
Gratiot Hillsdale Huron Ingham
Ionia Iosco Iron Isabella
Jackson Kalamazoo Kalkaska Kent
Keweenaw Lake Lapeer Leelanau
Lenawee Livingston Luce Mackinac
Macomb Manistee Marquette Mason
Mecosta Menominee Midland Missaukee
Monroe Montcalm Montmorency Muskegon
Newaygo Oakland Oceana Ogemaw
Ontonagon Osceola Oscoda Otsego
Ottawa Presque Isle Roscommon Saginaw
St. Clair St. Joseph Sanilac Schoolcraft
Shiawassee Tuscola Van Buren Washtenaw
Wayne Wexford