Supplier Registration Form

Please enter the information required below.

Company name:

Principal’s name and title:

Corporate address:

City: State: Zip:

Main phone:

Primary contact name & title:

Primary contact phone: Email address:

Web address:

Diversity certification by: Expiration date: No. years in business:

Diversity designation:

MBE WBE SBC DVBE SDB HUBZone Other

Gender:

Male Female

Ethnicity:

Hispanic American African American Asian American

Native American/Alaskan Asian/Pacific Island American Subcontinent Asian American

Average number of employees: Tax ID number: Gross annual sales:

Legal structure:

Corporation Partnership Sole proprietorship

Joint venture Franchise Non-profit

US citizen:

Yes No

Methods of payment accepted:

MasterCard-Visa American Express Credit cards not accepted

Purchase Order Check

Product or service category: (Select one sub-category from one of the main categories)

Human Resources / Facilities
Benefits ConsultingHR Services - GeneralStaffing - PermanentStaffing - TemporaryTraining / Automated Dispensing Equip Sales or MaintenanceBack Up Power (UPS Systems)Building Maintenance - GeneralConstructionData / Voice Cabling ServiceElectrical ServiceElectricityFacilitiesFacilities Equip - GeneralFacilities Equip Spare PartsFuel OilGasHVAC MaintenanceHVAC SalesJanitorial ServicesJanitorial SuppliesLandscape - Snow RemovalMaterial Handling EquipSafety EquipmentSafety ServicesSecurity EquipmentSecurity ServiceUtilities ServicesWaste Removal
Support Services / Technology
FoodserviceOffice EquipmentOffice Furniture / FittingsPublications and SubscriptionsRelocation ServicesTravel Agencies / Audio VisualHardwareHardware MaintenanceIT ContractorsIT HelpdeskSoftwareSoftware MaintenanceSystem IntegrationTechnology - GeneralTelecom
Packaging / Printing
Bottles / CapsContainers Coolant - Gel PacksCoolant - GeneralCorrugated Boxes Insulated Container - GeneralInsulated Container / BoxLabels and RibbonsPackaging - GeneralPaper SuppliesShipping Bags / Plastic MailersTemperature Sensitive PackagingVoid Fill / Commercial PrintingDirect Mail / Fulfillment Pre-PressPrinting - Envelopes
Professional Services / Marketing
Architectural ServicesAsset RecoveryBankingBusiness Services - GeneralEngineering ServicesFinancial ServicesInsuranceLegal Services Moving Services CommercialMoving Services EquipmentOutsourced ITOutsourcing - GeneralProfessional ServicesVehicle Fleet Services / Advertising AgenciesBenefit FairsCopywritingCreative Agencies - GeneralData and List ProvisionEcommerce / Web DesignEmployee RecognitionEvent Planning - GeneralFreelance WritersMarket ResearchMarket Research - GeneralMarketing - General Media Planning / BuyingPhotographyPromotional - General ASIPublic RelationsTrade Shows
Pharmaceuticals / Logistics
Drug Wholesaler / Air FreightCourierPallets / GaylordsShipping - GeneralTrucking LTLTrucking-General

Remit to address:

Instructions:

Complete all information on this form then email it along with a copy of your company’s third party certification to:

Upon completion of the supplier registration form, your company's information will be included in our Supplier Diversity database. This does not guarantee your company will be awarded business with Medco, however it is the initial step required to gain access to the Medco supply chain. If Medco has a business need for your company's products or services, you will be contacted at the appropriate time.

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Medco is a registered trademark and Medco making medicine smarter is a trademark of Medco Health Solutions, Inc.

Rev. 01/12