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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 Sheets
Max. file size: 50 MB.
Class of Trade Restrictions*
Is Your Business:*
Check any that apply
- Minority Owned
- Woman Owned
- Veteran Owned Business
- None of the above
Other GPO Contracts*
ie. Premier, Vizient, etc.
Has the company been excluded from participation in Medicare, Medicaid, or any state reimbursement programs?*
- Yes
- No
If yes, please explain.
Does your company have approval from all federal, state and local governments in the US?*
- Yes
- No
If yes, please describe.
Which geography does your company serve?*
Are products available direct, through distributors or both?*
- Direct Only
- Through Distributors Only
- Both Direct and Through Distributors
Customer Reference
Reference: Name
First Last
Reference: Company Name
Reference: Email
Reference: Title
Reference: Phone
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