Essential "Healthcare" Personnel Sticker

Essential "Healthcare" Personnel Sticker
Definition: For Healthcare Workers Providing Direct Patient Care

Versions - choose below
1. Sticker Form - Peel and Stick to back of badge, available for pick-up or mailed directly, Max quantity: 100 per organization.
2. Digital Form - Image file, can be added to your badge template if capable of printing your own.
Name of Agency/Facility*
County*
Agency/Facility Type*

HospitalHome Health / HospiceLTC (SNF,ALF, ICF/IID, CCRC)EMSDialysis ClinicOther
Point of Contact Name*

First NameLast Name
Point of Contact 24/7 Phone Number*
Point of Contact Email*
example@example.com
How would like to receive the Essential Personnel Stickers*

Physical Sticker - Pick-up (max 100)Physical Sticker - Direct Mail to Agency (max 100)Digital Copy - Will be Sent by Email
Quantity of Essential Personnel Stickers Needed*
Digital Copy: You will receive an email to the address placed ablove separately with an image attachment of the Essential Personnel Sticker Template.
Pick-up Instructions: Please wait for a confirmation email from Ms Roxie Ward before you come to pick up the stickers. YOU WILL NOT BE ABLE TO RECEIVE THE STICKERS WITHOUT THE CONFIRMATION EMAIL SENT TO YOU FROM MS ROXIE WARD DIRECTLY. THE AUTOMATIC RECIEPT GENERATED AFTER CLICKING SUBMIT DOES NOT COUNT, THIS IS JUST FOR YOUR RECORDS.

Pick-up Location: SETRAC Headquarters

1111 North Loop West, Ste 160

Houston, Texas 77008

Business Hours: Monday to Friday - 8.00am to 4.00pm
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Should be Empty: