Vizient

Supplier Diversity

Register to be a Diverse Supplier

Contact First Name:
Contact Last Name:
Contact Phone:
Contact Fax:
Contact Email:
Company Name:
Street Address 1:
Street Address 2:
City:
Zip:

Diversity Classification (select all that apply):

Minority Business Enterprise

Women Business Enterprise

Small Business Enterprise

Veteran Business Enterprise

Number of Employees:

Annual Company-wide Sales (in U.S. dollars):
$

Year:

Tax ID Number:

Duns Number:

Type of Business:


If "Other", please explain:

Please limit to 800 characters or less.

Type of Ownership:

Product/Service Category (select all that apply):


If "Other", please explain:

Please limit to 800 characters or less.

Product/Service Name(s):

List all, separating each with a comma. Please limit to 500 characters or less.

Mfg. Product/NDC Number, if available:

Has the FDA approved this product for sale and use in the United States?

Yes   No   N/A

If "Yes", enter PMA, 510(k), NDC or Exempt:

Is this product/service currently available on a Vizient contract?
Yes   No

If "Yes", what is the contract number?

List all, separating each with a comma. Please limit to 200 characters or less.

List competitors and competitive products:

List examples, separating each with a comma. Please limit to 800 characters or less.

List Web site(s) where interested parties can find information specifically about this product:

List examples, separating each with a comma. Please limit to 800 characters or less.

E-mail address to which health care organizations can submit questions or comments:

Please provide organization and contact information of current users of the product or service:

Please limit to 800 characters or less.


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