Application
To
apply for service from We
Check On You ,
fill out this form; print the completed form (use the
print facility under the file menu option), and mail
the completed form with your payment. You will be contacted
by telephone or email before your scheduled service
begins.
We
will need to verify the information provided.
All checks should
be made payable to RMT Enterprise and mailed,
with the completed form to:
RMT
Enterprise 878
Goettingen Street, Suite A, Telephone: 1-888-932-5668
Payments
may be in the form of a Personal Check, Cashier's
Check or Money Order.
Name
Address
City
State/
Phone
Email
Hours
to be contacted: AM
When we call, we will let the telephone ring
up to ten times.
If
you need more , let us know.
Yes
Are
You Taking Medication?
Yes
If
so, how many times per day? Once
Other
Emergency
Contacts (Friends or Relatives)
1.
Name
Phone
Address
City
State/
2.
Name
Phone
Address
City
State/
Please
provide us with additional information you feel we need
to know.
