Advocate Health Care
a patient or visitor a physician or healthcare professional an employer
Thank you for your interest in Advocate Health Care. 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.

* Indicates required information
Name of Company * 
Company Website * 
Street Address * 
City * 
State * 
Zip Code * 
Billing Address and Street Address are the same 
Billing Address 
Zip Code 
Company Phone * 
Company Fax 
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 

If Other, please specify:

If a minority-owned business, are you registered with a Minority Business Organization, Government Municipality or Agency * 
If yes, what is the name of the entity 
Are you certified by CMBDC/WBDC/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 Initative (MBI) * 
Type of Business (check all that apply) 

If Other, please specify:

If you are a manufacturer, please indicate type 
If you selected "Distribution Partners", please list names of your authorized distributors 
Please provide a brief description of services and/or products offered 
AHC is a member of the MedAssets GPO. Do you have a contract with MedAssets for this or any other product line * 
If yes, which ones 
Should you be awarded a contract, will you be able to sell/service all AHC facilities * 
If no, please explain 
Is your company compliant with 
GTIN - global trade identification number * 
GLN - global location number * 
Should you be awarded business by AHC a condition of our business relationship is vendor registration through REPTRAX. This process provides us with relevant information needed by our hospitals and corporate office. Contact 
Do you agree to register with Reptrax * 
Please list 3 customer references, including contact addresses and telephone numbers 
Please include any additional comments you have 
Authentication * 

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