HealthTrust Purchasing Group
MWBE Supplier Profile

 

The following information is required to establish your company in HealthTrust's database of MWBE potential suppliers of goods and services. We appreciate your interest in doing business with HealthTrust.
 

Note: This is a resource database only and does not constitute or imply a HealthTrust contract.
 

If you do not currently have MWBE certification, please obtain certification prior to completing and submitting this profile.
 

 

 1. General Information:
Supplier Name: 
Tax ID#:  (Numeric values only please)  
Address: 
City: 
State: 
Zip Code: 
Contact Title:   Mr.  Mrs.  Ms.
Contact Name: 
Phone: 
Fax: 
E-mail: 
Website: 
User Defined 1: 
User Defined 2: 
 
 2. Business Classification:
   Minority Owned
   Woman Owned
   Service Disabled Veteran Owned
Minority Ethnic Group:   
   Native American
   African American
   Hispanic American
   Asian-Pacific American
   Hasidic Jewish American
Certified by: 
   NMSDC Council
   SBA 8(a)
   WBENC
   Local Government
   State Government
   ASDV
   
Important: Mail/Fax copy of MWBE Certification.
Click here for mail/fax information
 
 3. Business Structure:
 
Legal Form of Organization:
   Sole Proprietor
   Partnership
   Corporation
   Franchise
Type of Business:
   Manufacturer
   Distributor
   Services
   Construction
Year Established: 
# of Employees: 
 
 4. Products and Services:
Major Category
 Medical/Surgical Supplies  Surgical Instruments
 Medical/Surgical Supplies Distr.  Lab Products/Distribution
 Pharmaceutical Products Distr.  Medical Equipment
 IT Products & Services  Promotional Products
 Construction  Office Supplies/Equipment
 Food Services  Medical Transcription
 MRO & Janitorial  Repair Services
 Staffing Services  Energy
 Transportation/Delivery Services  Telecommunications
 
List Products/Services: 
 
 5. Geographic Coverage Capabilities:
 
LocalRegionalNational
 
 6. Customer References:
 
Name: 
City/State: 
Phone: 
 
Name: 
City/State: 
Phone: 
 
 
 
Failure to complete this form properly will delay processing of your supplier profile.