GHFJ Health and Human Services Vendor Application
After you submit the form below you will be directed to PayPal to finalize payment and application submission. You do not need a PayPal account to pay this way, nor do you need to create one. No other form of payment is accepted. If you fill out the below form and do not make a payment when directed to PayPal your form information will be deleted and you will have to start over.
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  • This email will be used to send you confirmation of application submission along with what you have submitted. Please verify the email address you have entered is correct and accessible.
  • Agreement and Signature

    By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am issued a license, any false statements, omissions, or other misrepresentations made by me on this application may result in the immediate revocation of my license. I further agree to abide by all Federal and State laws prohibiting the sale and use of illegal drugs and alcohol and I also understand that if I or any of my employees are arrested for sale or use of illegal drugs and alcohol that such arrest is grounds for immediate revocation of my license and notification to the State and Federal agencies.
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