watch video


Thank you for your interest in Adventist Health System. In order to develop a more complete knowledge of your company and better match future company opportunities to your company's capabilities, please complete this form.

VENDOR PROFILE AND PRE-QUALIFICATION FORM
Name of Company*
Company Website
Street Address*
City*
State*
Zip Code*
Billing Address
City
State
Zip Code
Company Phone*
Company Fax*
Is this address the:*
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?
If yes, check all that apply


Other Ethnicity
If a minority-owned business, are you registered with a Minority Businss Organization, Government Municipality or Agency?
If yes, what is the name of the entity?
Are you certified by MMBDC/NMSDC/CEED or another certifying organization?
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?
Is your business women-owned?
If yes, what percent?
If yes, are you registered with the Majority Business Initiative (MBI)?
Type of Business (check all that apply)


Other Business Type
If you are a manufacturer, please indicate type
If you selected "Distribution Partners", check all that apply
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?
If yes, which ones?
Should you be awarded a contract, will you be able to sell/service our facilities nationwide?
If no, check all areas that apply:
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?*
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.

If the page appears frozen, or will not Submit, be sure to scroll up to ensure that all required fields have been completed as requested.
Submit
*Required