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 
City 
State 
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 reptrax@intellicentrics.com 
Do you agree to register with Reptrax * 
Please list 3 customer references, including contact addresses and telephone numbers 
First 
Second 
Third 
Please include any additional comments you have 
Authentication * 

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