VDN- Group Purchasing Application

Group Purchasing Application

Please fill out the form below to apply to become a member of our Group Purchasing Organization (GPO). To receive discount pricing on items that you commonly use, please provide your current product information below.

Business/Agency Name:

Tax Exempt?
Yes No
Please make a selection.

Contact Person:
Please provide a contact.

Department & Title:

Office Phone:
Please provide a phone number.Please use the correct format (999) 999-9999.

Fax Number:
Please use the correct format (999) 999-9999.

Cell Phone:
Please use the correct format (999) 999-9999.

Email Address:
Please provide a valid email address.Please provide a valid email address.

Web Site :

Address:
Please provide an address.

City:
Please provide a city.

State:

Zip:
Please provide a zip code.Please use the correct format 99999.

Please list items that you are currently using to obtain a discounted quote from VDN.
Manufacturers Name	Mfg Item#	Current Price	UOM	Description

Additional information including ship to address: