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1. Welcome
CONTRACTOR TYPE
*
2. Profile Details Information
VENDOR REQUEST TYPE :
New contract
Vendor Request Type Text
*
What is your organization's Legal Business Name?
*
What is your organization's "doing business as" ?
*
What is your organization's FEIN (Tax ID Number)?
*
Country :
USA
Country Text
*
Ever operated under a different business name?
Ever operated under a different business name?
No
Ever operated under a different business name?
Yes
Business name(s) your organization used in Past :
*
Primary Place of Business Street Address Line 1 :
*
Primary Place of Business Street Address Line 2 :
*
Primary Place of Business city :
*
Primary Place of Business state :
*
Primary Place of Business zip code :
*
What is your organization's website URL?
*
Does your organization have a D&B Number?
Yes
No
Provide your organization's D&B number :
*
Person to be contacted for Contracting Purposes First Name :
*
Person to be contacted for Contracting Purposes Last Name :
*
What is the contact person's email address?
*
*
What is the contact person's phone number?
*
Is there a point of contact at Vaya Health?
Yes
No
If yes, what is the Vaya POC's name?
*
Will organization provide Goods, Services or Both?
Goods
Services
Goods and Services
Goods Or Services Text
*
Describe the Goods and/or Services provided :
*
Describe the Goods and/or Services provided :
*
Other information regarding your organization :
*
Are you uploading documentation in support of this registration?
Are you uploading documentation in support of this registration?
No
Are you uploading documentation in support of this registration?
Yes
3. Key Business Information
Type of industry in which supplier operates :
*
Select the category of product/ services provided :
category of product/ services provided Text
*
Name the Products OR Service Provided :
*
Upload Supporting Documentation
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