Prospective Vendor Request Form
*Required Fields

DISCLAIMER: This is for informational purposes only. This is an application to request consideration to become an HealthTrust vendor.
PLEASE READ: Thank you for your interest in becoming a HealthTrust Purchasing Group (HealthTrust) contracted supplier. Your profile information will be kept on file until such time this product line falls within our contract plan and if your company meets HealthTrust’s criteria. Due to the tremendous volume of profiles, we ask that you do not contact us by phone to inquire on the status of your profile or our contracting plan.
Enter your initials to accept the above conditions: *  

Company Name: *
Address: *
City: *
State: *
Zip: *
Telephone: *
Toll-Free No.:  
Fax:   
E-mail: *
Web Site:  
Ownership Status:   Corporation
Joint Venture
Limited Liability Company
Partnership
Private
Proprietorship
Public
If Minority Concern, Please Complete This Section:    
 A. Small Disadvantaged Business Concern:   Asian Pacific American
 Black
Hasidic Jewish American
Hispanic
Native American
Subcontinent Asian American
Not Applicable
B. Certified Small Business Concern:
(As defined by the small business act)		   Yes       No
C. Women-Owned Small Business:   Yes      No
Geographic Service Area:   International
Local
National
Regional
Approximate Sales Volume for  
Current Year's Rolling 12 Months:  
Previous Year's Rolling 12 Months:
Information Products or Services:
(Please check all that apply) 		  Clinical Capital Equipment
Clinical Supplies
 Food Procurement & Services
 Information Technology Products & Services
 Laboratory Equipment & Supplies
 Non-Clinical Supplies
Non-Clinical Capital Equipment
Other-Products & Services - Please Explain:
What percentage of your business is direct?  *
What percentage of your business is through a distributor?  *
How many distributors do you have?   *
What is the name of your National Sales Manager?  *

BUSINESS CLASSIFICATION DEFINITIONS
A. SMALL BUSINESS CONCERN: A small business concern, including its affiliates, which is independently owned and operated, is not dominant in the field of operation in which it is competing and can further qualify under the criteria concerning the type of business, number of employees, average annual receipts, or other criteria as defined by the Small Business Act and relevant regulations published. For example, all contracts of $10,000 or less, a company is determined to be small and if it does not have more than 500 employees including its affiliates.
B.

SMALL DISADVANTAGED BUSINESS CONCERN: A small concern that is at least 51% owned and controlled by socially and economically disadvantaged individuals, and whose management and daily business operations are controlled by one or more of those individuals: (A) Socially disadvantaged individuals are those who have been subjected to racial or ethnic prejudice or cultural bias because of their identity as a member of a group without regard to their individual qualities: (B) Economically disadvantaged individuals are those socially disadvantaged individuals whose ability to compete in the free enterprise system has been impaired due to diminished capital and credit opportunities compared to others in the same business area who are not socially disadvantaged. Contractors shall presume that socially and economically disadvantaged individuals include citizens of the U.S. identified below. Hasidic Jewish Americans have been classified as socially disadvantaged by the U.S. Department of Commerce Minority Business Development Agency.

  1. Black Americans
  2. Hispanic Americans
  3. Native Americans
  4. Asian-Pacific Americans
  5. Subcontinent Asian Americans
  6. Hasidic Jewish Americans
C. WOMEN-OWNED BUSINESS CONCERNS: A business concern that is at least 51% owned by women or women who are U.S. citizens, and who also control and operate the business. Women as a class are not considered to be socially and economically disadvantaged.