Company Profile Form

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Name of Company*

Name of Parent Company (if applicable)

Company Website

Street Address*

City*

State*

Zip*

Company Phone*

Company Fax

Year Company Started

Number of Employees

Annual Revenue

Please provide an overview of the company*

Primary Contact Name*

Primary Contact Phone*

Primary Contact Title*

Primary Contact Email*

Secondary Contact Name

Secondary Contact Phone

Secondary Contact Title

Secondary Contact Email

Do you make/manufacture a product?*

Yes No

If yes, please list products

Do you distribute products?*

Yes No

If yes, please list the brand and product

Do you provide services?*

Yes No

If yes, please list services

Is your service or product construction related?*

Yes No

If yes, please provide details

Do you sub-contract labor?*

Yes No

If yes, please provide details

Do you currently provide goods or services to any AdventHealth facility? If so, please list locations*

D & B DUNS Number

Please provide W-9, W-8, or 1042 for your company (upload copy):*

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Are you considered by the IRS to be self-employed or an independent contractor requiring the use of IRS form 1099?*

Yes No

Do you have a relationship with Premier Inc., a Group Purchasing Organization?*

Yes No

Are you a certified diverse supplier?*

Yes No

If yes, check all that apply

SBE - Small Business Enterprise WBE - Women-Owned Business Enterprise MBE - Minority-Owned Business Enterprise VBE - Veteran-Owned Business Enterprise LGBTBE - Lesbian, Gay, Bisexual, Transexual, and Transgender Business Enterprise

Please provide Certification Number for SBE - Small Business Enterprise

Please provide Expiration Date for SBE - Small Business Enterprise

Please upload a certification copy for SBE - Small Business Enterprise

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Please provide Certification Number for WBE - Women-Owned Business Enterprise

Please provide Expiration Date for WBE - Women-Owned Business Enterprise

Please upload a certification copy for WBE - Women-Owned Business Enterprise

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Please provide Certification Number for MBE - Minority-Owned Business Enterprise

Please provide Expiration Date for MBE - Minority-Owned Business Enterprise

Please upload a certification copy for MBE - Minority-Owned Business Enterprise

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Please provide Certification Number for VBE - Veteran-Owned Business Enterprise

Please provide Expiration Date for VBE - Veteran-Owned Business Enterprise

Please upload a certification copy for VBE - Veteran-Owned Business Enterprise

No File Chosen

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Please provide Certification Number for LGBTBE - Lesbian, Gay, Bisexual, Transexual, and Transgender Business Enterprise

Please provide Expiration Date for LGBTBE - Lesbian, Gay, Bisexual, Transexual, and Transgender Business Enterprise

Please upload a certification copy for LGBTBE - Lesbian, Gay, Bisexual, Transexual, and Transgender Business Enterprise

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Other Diverse Supplier Classification*

Yes No

Name of the Certification

Certification Number

Please provide certification expiration date

Please upload a copy of your Certification

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DISCLAIMER:

Submission of a Company Profile Form does not automatically place your company on a "bidder's list”, constitute approval of your company as an AdventHealth supplier, or obligate AdventHealth to solicit a request for quotation. It does, however, allow us to better understand your business capabilities to meet AdventHealth’s goals and objectives.

If an opportunity for your product or service is identified, you will be contacted by AdventHealth Strategic Supply Chain for additional information.