Please fill out the form below to be considered for a supplier contract with CNECT GPO. Company Name*Name* First Last Email* Phone Number*Product/Service Name*Company Website*Product/Service Description*Upload Any Marketing Materials and/or Fact SheetsClass of Trade Restrictions*Is Your Business:*Check any that apply Minority Owned Woman Owned Veteran Owned Business None of the aboveOther GPO Contracts*ie. Premier, Vizient, etc.Has the company been excluded from participation in Medicare, Medicaid, or any state reimbursement programs?*YesNoIf yes, please explain.Does your company have approval from all federal, state and local governments in the US?*YesNoIf yes, please describe.Which geography does your company serve?*Are products available direct, through distributors or both?*Direct OnlyThrough Distributors OnlyBoth Direct and Through DistributorsCustomer ReferenceReference: Name First Last Reference: Company NameReference: Email Reference: TitleReference: PhoneCAPTCHA