SCRIP VENDOR ENROLLMENT FORM

Company Name:__________________________________________________________

Address:________________________________________________________________

Phone:______________________________Fax:________________________________

Contact Name:___________________________________________________________

Email:__________________________________________________________________

Discount Percentage Offered:__________________%

The Scrip check will be sent to

MVCDS-SCRIP,

1715 South Reynolds Road, Toledo, OH 43614:

_______________every order ___________________monthly

Thank you for participating in the MVCDS Scrip Program!!

Please return this form to:

MVCDS SCRIP PROGRAM

1715 South Reynolds Road

Toledo, OH 43614

Or fax to 419-381-8341