Supply Chain Vendor Application

Please select one:

• New Submission: Correction/Update:

• Legal Company Name: *
• Company Name (eg DBA):
• Address: *
• City: *
• State: AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MI MA MD MI MO MN MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip: *

• Legal Company Name:
• Company Name (eg DBA):
• Address:
• City:
• State: AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MI MA MD MI MO MN MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip:

Check all that apply.

• Corporation/LLC, Sole Proprietor or Partnership
• Profit
• Publicly held
• Non-Profit/Public Sector
• Franchise
• Independent Contractor
• Subsidiary
• Distributor
• Service Provider
• Labor Services
• Manufacturer
• Small Business
• Other

Number of Employees

• 1
• 2-10
• 11-20
• 21-50
• 51-100
• 101-200
• 201+

• Total sales last fiscal year:
• Year Business Established:
• Federal Tax ID No.:

Please provide the name, address and phone number of two corporations for whom you have provided services in the past 12 months.

A business is considered US Owned if the basic contactual and legal responsibilities for its operation reside within the US, its territories or possessions.

• US Owned
• Not US Owned

• Contact Person: *
• Title:
• Phone Number: *
• Fax Number:
• Email: *
• Web Address:

Are one or more of your employees represented by an union?

• Yes
• No

Is your company equipped for EDI (electronic data integration)?

• Yes
• No

Please complete this section if you are a certified small business enterprise (SBE), minority owned business (MBE), or a woman owned business enterprise (WBE). The intent of the Health Alliance Supplier Diversity program is to increase the amount of goods and services purchased from certified SBE, MBE, and WBE vendors.

Check all that apply.

• MBE - A business that is at least 51% owned, managed and controlled by US citizens and are an African American, Hispanic American or Native American
• WBE - A business that is at least 51% owned and controlled by US citizens who are women
• SBE - Generally, a business is considered "small" based on the following: manufacturer - fewer that 500 employees, distributor or wholesaler - fewer than 100 employees, retail trade, professional services or health care related company - receipts for small business may range from $5-$25 million, depending on the SIC and/or the NAICS codes.

Please attach the following:
If you are a Certified Diversity vendor, please attach your current certificate from that Certification Agency. Also, please attach either marketing material or a brief description of your business to help us understand your products or services specific to Healthcare.

You may attach up to 3 documents to your application. Attachments may be in Adobe PDF, Microsoft Word, Microsoft Excel, Microsoft Powerpoint, or plain text format only. Each attachment may be no larger than 2MB. Attachments that do not conform to these guidelines will be ignored.

When all sections are complete, press the "Submit Application" button.

Some required information is missing. Please scroll up and enter information in the fields outlined in red.