Supplier Registration Form - Advantus Health Partners

"*" indicates required fields

Fill out all the information as it applies to your business.

Supplier Name*

Employees

Avg. Revenue for Last Three (3) Complete Fiscal Years (USD)

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Person*

First Last

Contact Email*

Contact Phone*

Website

Product/Services*

Check all the apply:

Women‐owned Business (WBE / WOB)

Minority‐owned Business (MBE / MOB)

LGBT‐owned Business (LGBTBE / LGBTOB)

Veteran‐owned Business (VBE / VOB)

Service‐disabled Veteran‐owned Business(SDVBE)

Disability‐owned Business (DOB / DOBE)

Other:

Government Classification:

NAICS Codes separated by commas

Certifications:

Self-Certified

Certified by 3 rd Party

Certifying Agency

Certification Origination Date

Certificate Number

Certification Expiration Date

**Please provide copy of Certifications with form submission

Drop files here or

Accepted file types: pdf, jpg, png, doc, docx, Max. file size: 50 MB.

Category Indicator*

Phone

This field is for validation purposes and should be left unchanged.