Please Complete This Form (Type Or Print Clearly) and Return To

Supplier Profile Form

Please complete this form (type or print clearly) and return to:

HealthEast Corporate Materials Management

1700 University Ave.
St. Paul, Minnesota 55104

Company Name: ______

Local Address:______

______Phone Number:______

Corporate Office Address:______

______Phone Number:______

Remittance Address: ______

______Phone Number:______

Web site Address: ______

Date Company Established:______

Type of Business:

A. ( ) Manufacturer ( ) Distributor ( ) Other:

B. ( ) Corporation ( ) Privately Owned ( ) Partnership ( ) Other:

Products and/or Services Rendered (attach line card if available):

______

Current products and/or services provided to HealthEast

(indicate source of distribution):

______

Please list any subsidiary/affiliated companies:

______

St. Paul Area Representation/Contact

Name: Title:______

Mailing Address:______

Phone Number:______Fax Number:______

Email Address:______

Area Sales Manager

Name: Title:______

Mailing Address:______

Phone Number:______Fax Number:______

E-mail Address:______

Company President

Name:______Phone Number:______

Customer Service Information

HealthEast Account Number(s):______

Customer Service Contact Name:______

Phone Number:______Fax Number:______

E-mail Address:______

Payment Information

Indicate Standard Payment Terms:______

Indicate Prompt Payment Discounts Available:______

Ordering Information

Capabilities: ( ) EDI ( ) Fax ( ) Internet ( ) Other

What is your process(s) for customers to place orders:

______

What is your “Return Goods” Policy & Procedure:

______

What is your “Sample/Evaluation Product” policy:

______

What is your “Freight” policy?: ( ) F.O.B. Destination (no charge) ( ) Other, please indicate below

______

Do you provide MSDS Sheets? ( ) Yes ( ) No

Quality Improvement Program

Does your company have a “Quality Improvement Program” in place? ( ) No ( )Yes

If “Yes”, how does this program impact and/or benefit customers such as HealthEast?

______

Is your company ISO Certified? ( ) No ( )Yes

Waste Reduction Program

Does your company have a “Waste Reduction Program” in place? ( ) No ( )Yes

If “Yes”, how can this program impact and/or benefit customers such as HealthEast?

______

Value Added Programs

Please indicate any “Value Added” programs and/or additional services available (such as technical assistance, consignment, maintenance, emergency expediting, education, training, etc.):

______

Standard Form Contract and Price Lists

Please provide a copy of the company’s standard form contract and current published price listings.

( ) Attached

Vendor Insurance Information

Please provide the following insurance information.

A. Coverage Limits:

General Liability including products/completed operations. $ ______

Workers Compensation. $ ______

Auto Liability. $ ______

B. Insurance Company:______Address:______

C. Insurance Agency:______

Address:______

Vendor Financial Information

Please provide a copy of your most recent annual report or current balance sheet statement.

( ) Attached

References

Please provide at least three (3) client references, preferably health care-related and based in the Minnesota area. Include contact names, telephone numbers and length of relationship.

( ) Attached

Conflicts of Interest

Does any Physician, practicing at HealthEast, or HealthEast employee have ownership, investment interest in, or a compensation arrangement with your company? ( ) No ( ) Yes, If ‘Yes’ please provide details : ______

HealthEast Policies & Procedures

Vendors are responsible for complying with HealthEast Policies and Procedures.

Please review these policies.

Management Signature: Date:______

Title:

Thank You!