COVID-19 Community Vaccine Provider Request Form Provider Details NAME OF PROVIDER:
PHONE NUMBER:
MAIN CONTACT(S):
Event details or resources required
This form is to request additional resources to support the COVID-19 vaccination programme. This may include resources such as posters or advertising, or funding to support initiatives like activities at events. Please consider how your initiative will impact access to vaccination for Māori.
EMAIL:
ADDRESS:
RESOURCE(S) REQUIRED:
DEADLINE:
ESTIMATED COST OF INITIATIVE:
PROPOSED INITIATIVE: (Please provide a brief outline of what you are intending to do i.e. Saturday morning clinic coffee cart)
DATE(S) THIS INITIATIVE WILL TAKE PLACE:
Requests to be emailed to promo.orders@bopdhb.govt.nz
Office Only
APPROVAL:
RECEIPT OF INVOICE:
DATE PROVIDER NOTIFIED OF OUTCOME:
PAYMENT: