Supplier Registration Form
Please enter the information required below.
Company name:
Principal’s name and title:
Corporate address:
City:
State:
Zip:
Main phone:
Primary contact name & title:
Primary contact phone:
Email address:
Web address:
Diversity certification by:
Expiration date:
No. years in business:
Diversity designation:
MBE
WBE
SBC
DVBE
SDB
HUBZone
Other
Gender:
Male
Female
Ethnicity:
Hispanic American
African American
Asian American
Native American/Alaskan
Asian/Pacific Island American
Subcontinent Asian American
Average number of employees:
Rev. 01/12
Tax ID number:
Gross annual sales:
Legal structure:
Corporation
Partnership
Sole proprietorship
Joint venture
Franchise
Non-profit
MasterCard-Visa
American Express
Credit cards not accepted
Purchase Order
Check
US citizen:
Yes
No
Methods of payment accepted:
Product or service category: (Select one sub-category from one of the main categories)
Human Resources
Facilities
Support Services
Technology
Packaging
Printing
Professional Services
Marketing
Pharmaceuticals
Logistics
Remit to address:
Instructions:
Complete all information on this form then email it along with a copy of your company’s third party certification to:
supplierdiversity@medco.com
Upon completion of the supplier registration form, your company's information will be included in our Supplier Diversity database. This does
not guarantee your company will be awarded business with Medco, however it is the initial step required to gain access to the Medco supply
chain. If Medco has a business need for your company's products or services, you will be contacted at the appropriate time.
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Medco is a registered trademark and Medco making medicine smarter is a trademark of Medco Health Solutions, Inc.
© 2010 Medco Health Solutions, Inc. All rights reserved.
Rev. 01/12