Profile and Prequalification Form | Adventist Health System

Name of Company*

Company Website

Street Address*

City*

State*

Zip Code*

Billing Address and Street Address are the same

Billing Address

City

State

Zip Code

Company Phone*

Company Fax*

Is this address the:*
Main OfficeRegional OfficeBranch Office

Name of Parent Company (if applicable)

Address of Parent Company (if applicable)

Contact Name*

Contact Phone

Contact E-mail

Contact Name

Contact Phone

Contact E-mail

Is your company minority-owned?
YesNo

Other Ethnicity

If a minority-owned business, are you registered with a Minority Businss Organization, Government Municipality or Agency?
YesNo

If yes, what is the name of the entity?

Are you certified by MMBDC/NMSDC/CEED or another certifying organization?
YesNo

If yes, what is the name of the entity?

If yes, what is the certification expiration date?

If no, are you in the process of certification?
YesNo

Is your business women-owned?
YesNo

If yes, what percent?

If yes, are you registered with the Majority Business Initiative (MBI)?
YesNo

Other Business Type

If you are a manufacturer, please indicate type
Direct Sales Only
Distribution Partners

Please provide a brief description of services and/or products offered*

AHS is a member of the Premier GPO. Do you have a contract with Premier for this or any other product line?
YesNo

If yes, which ones?

Should you be awarded a contract, will you be able to sell/service our facilities nationwide?
YesNo

Should you be awarded business by AHS, a condition of our business relationship is vendor registration through Vendormate. This process provides us with relevant information needed by our hospitals and corporate office. There is a yearly fee per company tax ID number based on the type of business. Once registered sales reps will be able to register at our many hospitals without further payment.

Are you willing to register with Vendormate, if asked?*
YesNo

Please list 3 customer references, including contact addresses and telephone numbers*

Please include any additional comments you have:
(2000 characters max)

Click the Submit link below to validate your form entries and complete your registration. A copy of your information will be delivered to the first contact e-mail address you listed above.

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