Request Supplies

Health Share Supply Order Form

Please complete this form when requesting supplies for your department. Requests for supplies are processed during normal business hours and may take up to 7 to 10 business days to be delivered. Please plan in advance when requesting passes for your department. DO NOT USE THIS FORM TO SEND ITEMS TO CLIENTS.
Supply Requester Information
Name*
First Last
Email*
Phone*
Please indicate the specific RAE on whose behalf you are ordering supplies:*
- Clackamas County
- Kaiser Permanente
- Multnomah County
- Providence
- Washington County
- Tuality
Department*
Delivery Information
Attn:
Company
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Special Instructions
Shelter Voucher and Meal Coupon Selection
Please enter the number of booklets or coupons that you are ordering for your department. Allow 3 to 4 business days for passes and/or vouchers to be delivered.
City Team Ministries Voucher Booklet(s) - 25 vouchers per booklet
Sisters of the Road Meal Coupons
Transit Pass Selection
*UPDATE* Trimet has discontinued the pink foil-stamped paper tickets and will no longer be accepting them after December 31st, 2019. They have fully transitioned over to the HOP program and have replaced the pink ticket booklets with single use paper HOP passes. As the booklets are no long available, please enter the number of single use passes that you are ordering for your department.
TriMet Adult 2.5 Hour Single Paper Tickets - Enter total number of individual tickets needed
TriMet Adult All Day Single Paper Tickets - Enter total number of individual tickets needed
TriMet Honored Citizen 2.5 Hour Single Paper Tickets - Enter total number of individual tickets needed
TriMet Honored Citizen All Day Single Paper Tickets - Enter total number of individual tickets needed
TriMet Youth 2.5 Hour Single Paper Tickets - Enter total number of individual tickets needed
TriMet Youth All Day Single Paper Tickets - Enter total number of individual tickets needed
TriMet LIFT 2.5 Hour Single Paper Tickets - Enter total number of individual tickets needed (please only enter multiples of 10)
TriMet Blank Adult HOP Cards - Enter total number of individual cards needed. These cards do not have any value loaded. You must make separate requests in CLARA for them to be loaded.
TriMet Blank Honored Citizen HOP Cards - These can only be used for clients who have already applied and been accepted into Trimet's Honored Citizen program, or are over the age of 65. Enter total number of individual cards needed. These cards do not have any value loaded. You must make separate requests in CLARA for them to be loaded.
TriMet Blank Youth HOP Cards - These can only be used for clients under the age of 18. Enter total number of individual cards needed. These cards do not have any value loaded. You must make separate requests in CLARA for them to be loaded.
Cell Phones and Minute Cards
Please fill out this section when requesting additional cell phones and/or prepaid minute cards for your department. Please use CLARA to record or request phones for individual clients. Allow 7-10 business days for cell phones and prepaid minute cards to be delivered. Please plan in advance. If a specific phone or minute card brand is needed, specify below.
Cell Phones
Standard Prepaid Minute Cards
Supplemental $10.00 Minutes Cards to Cover Plan Price Increase
If necessary, indicate the specific brand needed:
Notes/Comments
Please indicate any notes or comments about this order

C3CAP

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Request Supplies

Health Share Supply Order Form

Supply Requester Information

Delivery Information

Shelter Voucher and Meal Coupon Selection

Transit Pass Selection

Cell Phones and Minute Cards

Notes/Comments