Supplier Preliminary Questionnaire

In order to better understand your business, and as a first step in establishing and maintaining a good business relationship with you, we request that you please provide us with the following information. Thank You.

GENERAL INFORMATION:

Company Name:
Primary Address:
City, State, Zip Code:
Web Site:
Primary Contact Name & Title:
E-mail Address:
Telephone:
Fax:
COMMODITIES OF INTEREST / CAPABILITIES :

WORLD-WIDE FACILITY INFORMATION: List the regions in which you provide world-

wide services either directly or through a joint venture (JV)
Location / Owned / JV / Services
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BUSINESS INFORMATION:

Business Structure: Sole Proprietorship Partnership Corporation
Current owner:
Other owner(s) over the past 5 years (if applicable):
When was your company established?
Sales over previous two years (U.S. Dollars):
Projected sales over the next 2 years (%):
SBA Certified Classification:
List of Current Registrations / Certifications:
Do you have a Disaster Recovery plan?
List the type and % of business you outsource to an alternate supplier.
Do you have a supplier management program to manage your supply base?
Please list your current revenue profile by sectors (medical, automotive) / % of Business
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Please list your top five customers and their % of your business / % of Business:
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PERSONNEL INFORMATION:
Number of Full Time Employees: / # In Engineering: / % Contract:
Number of Part Time Employees: / # In Purchasing: / Other:
# In Quality: / # In Manufacturing:

SERVICE INFORMATION:

Do you have Electronic Fund Transfer Capabilities? Yes No
Do you have in-house tooling capabilities? Yes No
Are you able to participate in new product design? Yes No
Do you offer any other value add services? Yes No
Other Services (please list and explain:
Supplier Representative Signature:
Supplier Representative Printed:
Date:
Thank you for completing Welch Allyn’s preliminary supplier questionnaire. Please scan this document, along with any additional marketing or sales information you would like to provide to:

We will ensure that your information reaches the appropriate Commodity Manager who will contact you if they have additional questions or in the event we would like to further discuss your capabilities.

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