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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 product information below.
Business/Agency Name:
 Tax Exempt?
 
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: