Prospective Supplier Registration Form

*Marked fields are mandatory

Acknowledgement

*By checking the box, I agree with this acknowledgement statement.

(1) The Resource Group has oversight of the entire contracting process for Participants*.

(2) Decision Teams and Specialty Affinity Groups, comprised of physicians, clinicians, and other subject matter experts, determine the necessary product and service attributes for contracting.

(3) Product samples, which may create substantial legal and patient safety risks, will not be left behind at the facilities of The Resource Group Participants.

(4) The products and services submitted for potential consideration will be contracted through The Resource Group's group purchasing organization (GPO).

(5) I understand that any false statements or inaccuracies within the information I submit may preclude me and the company I represent from having any further consideration with The Resource Group and its Participants.

*Participants include all Ascension owned and managed facilities as well as potential non-affiliated health, educational, or industrial institutions that are served by The Resource Group.

* 1. Contact Information

*First Name

*Last Name

*Contact Title

*Email

*Cell Phone Number (___) ___-____

Phone Number (___) ___-____ x_____

Fax Number (___) ___-____

* 2. Company Information

*Company Name

*Doing Business As (DBA)

*Do you have a headquarters in the United States? Yes No

*Address

*City

*State

*Zip

*Taxpayer Identification Number (TIN)

*Company Website

Ticker Symbol

Total Sales for last Fiscal Year

SG&A as a Percent of Revenue

R&D as a Percent of Revenue

* 3. Please select "Yes" to all that apply to your company

*Are you a Manufacturer? Yes No

A business that designs and coordinates the production of goods from raw materials or other OEM products.

*Are you a Distributor? Yes No

A business that has exclusive rights to market and sell, within a given territory, the products of a manufacturer or company. This may include a reseller's private label product.

*Are you a Service Provider? Yes No

A business whose core offering is a service rather than a manufactured product. Services include consulting, food and nutritional services, laundry, and others.

* 4. Are you a U.S. owned business?

Yes No

* 5. How does your company provide products (select all that apply)?

Directly to Customer?

Third Party Distributors of The Resource Group – Owens & Minor (medical and surgical supplies), McKesson (pharmacy), Cardinal Health (lab), Cardinal Health SPD (specialty pharmaceutical products)?

Service Provider?

* 6. Has your company been the subject of any regulatory, administrative, or judicial action, sanction, prosecution, or proceeding that would affect your ability to supply products or services?

Yes No

* 7. Has your company been excluded from participation in Medicare, Medicaid, or any state reimbursement programs?

Yes No

* 9. Please list the company names of competitors for the products or services you would like to submit for review and consideration.

Note: Please separate by commas

* 10. What is the total U.S. market share of your company compared to each of your competitors within the product or service category you would like to submit for review and consideration?

* 12. Briefly discuss your functional organization and the specifics of your company's sales force. Is the sales force outsourced or managed internally? Who is responsible for the management of servicing or repairing the products or services provided by your company?

Character left : 250 Max character (250).

*Total Sales Force Size

* 13. Please select the reason you are submitting a product or service for review and consideration (check all that apply)

Improved patient care

Reduce costs

Requested product or service

Other

* 15. Please download the Individual Product or Service Submission File template and submit all detailed product or service information below for review and consideration Download Template

Link to File

*Individual-Product-or-Service-Submission-File

*Please upload marketing materials such as detailed Product or Service information sheet(s)

*Please upload all Material Safety Data Sheets, ISO Certifications (e.g. 9000, 9001, 9002, 13485) and Product or Service liability insurance that would be applicable to this request.

* 16. Is your company an original manufacturer or reseller of this product?

Manufacturer

Reseller

N/A

* 17. Can your company provide the country of origin and manufacturing composition of the product(s) being submitted for review and consideration?

Yes No

* 18. Can your company demonstrate the technical merit of this product or service through published studies, proven sales history or any other means?

Yes No

* 19. Describe what is uniquely advantageous about this product or service. How is this different from the offerings of your competitors?

Character left : 250 Max character (250).

* 20. Please explain how the product or service you are submitting is beneficial.

Character left : 250 Max character (250).

* 21. Does this product require additional supplies and/or equipment?

Yes No

* 22. Will this product or service require additional physician or clinician training?

Yes No

* 23. Is this product or service meant to replace any other product or service currently being used by the Participants of The Resource Group?

Yes No

* 24. Is this product or service on contract and being used by another Participant of The Resource Group?

Yes No

* 25. Has there been a recall on any of the products being submitted for review and consideration?

Yes No

* 26. Is the product or service approved by all applicable federal, state (all 50 states) and local regulatory agencies in geographies currently serviced by The Resource Group?

Yes No

* 27. Please provide the necessary contact information of someone within your organization that will have signing authority for a potential contract with The Resource Group:

*Job Title

*First Name

*Last Name

*Email

*Phone Number (___) ___-____

*City

*State

*Zip

Testimonials

Reflecting back on my past three years with The Resource Group, it's become clear to me that the analyst program is truly a leadership development program. I've been able to explore all areas of The Resource Group, worked with multiple leaders in the company, and built my skill set through project management, implementation, and analytics.

Molly Albrecht, Area Senior Solution Specialist

Prospective Supplier Registration Form

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