Vendor

To be a vendor fill out this form, or click to print form.

CONTACT INFO (All correspondence will be sent to this person.)

* Indicates required field

Name *

First

Last

Title *

Company/Organization *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Fax *

Email *

Organization Type *

IF OTHER PLEASE INDICATE AMOUNT *

PAYMENT TYPE *

BY CHECKING THIS BOX *

YES, I AGREE TO SEND PAYMENT TO: NCADD-GDA, Attn: MI Celebrate Recovery 2400 E. McNichols, Detroit, MI 48212

DATE *

Submit

If you need access to care, contact:
County - Macomb - MCCMH
1 (855) 996-2264
County - Oakland - OCHN
1 (800) 231-1127
County - Wayne - DWIHN
1 (800) 241-4949