201 S. Cortez Street
Prescott, AZ 86303
Address of Company
Name of Person Applying
Please upload the company W9
Please upload a brief summary of expenses related to administering the vaccine.
I attest that the funds received from the City of Prescott will be used for the sole purpose of reimbursing actual expenses incurred by the company I represent in administering the COVID-19 vaccine in the Prescott area.
City staff will reach out once the application is submitted to notify of status and to explain next steps.