Vendor Application

Corporation/Firm

Company:

Address:

City:

State:

Zip Code:

Company Website:

Contact Name:

Phone:

Fax:

Email Address:

Products/Services

Describe products and/or services offered:

Nearest Shipping/Service Facility

Address:

City:

State:

Zip Code:

Telephone:

Primary Business Classification (check one)

Electronic Capability

What transaction sets do you have? Please check all that apply:

Please complete the following:

Is your company a small business? (Less than 500 employees) YesNo

Is your company minority-owned? YesNo

African AmericanNative AmericanHispanic American
Asian-Pacific AmericanAsian-Indian AmericanOther Specify:

Is your company woman-owned? YesNo

Is your company certified as a minority or woman-owned business? YesNo

If you are certified, by whom? CityStateWBENC Affiliate
CountyNMSDC AffiliateOther Specify:

Does your company have an established environmental or "green policy"? YesNo

If not, what are you plans to establish one?

Please print a copy for your records. Confirmation that your application has been received will be via email only. Submitting this information does not automatically make you a vendor to the Memorial Healthcare System. Your company's information will be added to our department database that is shared with Purchasing and other internal departments, as well as other companies who may have a need for your products/services. Your company's information may be shared with outside corporations who may have a need for your products/services.

If you have questions, you may contact Vendor Relations at 954-276-6461, or Email:venrel@mhs.net

If Mailing, please return to:

Memorial Healthcare System Support Services
2900 Corporate Way, Door C
Miramar, FL 33025-3925
Attn: Vendor Relations/Purchasing Department

Thank you for your inquiry!