Supplier Registration Form - Advantus Health Partners

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Supplier Identification Details

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*

Supplier Diversity Classification

Any questions or concerns relating to this document, classification definitions, or BSMH's Supplier Diversity Program overall should be directed to the Supplier Diversity Program via email, SupplierDiversity@mercy.com

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:

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

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Category Indicator*

Name

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(888) 383-8000

Supplier Identification Details

Supplier Diversity Classification