Vendor Registration
1. Contact Info	2. Done

Vendor Registration

Welcome to the Health and Hospital Corporation of Marion County vendor registration site. To process your registration efficiently, please provide all requested information. Some information is mandatory and you will not be able to complete your registration without it. Upon receipt of your completed registration, you will receive an E-Mail confirmation of your vendor registration. Thank you for taking the time to complete our vendor registration. If you have questions or need assistance with the registration process, please contact the purchasing department.

Contact Info
* Required Fields
New Vendor or Change of Information*	New Vendor Change of Information
Vendor / Company Name*
Owner Name(s) (list additional names below)*
Additional Owner Name(s)
Additional Owner Name(s)
Federal I.D. or Social Security Number*
Mailing Address for POs / RFQs*
Mailing Address for Payment (if different)
Toll Free Telephone Number (xxx-xxx-xxxx)
Phone (xxx-xxx-xxxx)*
Fax Number (xxx-xxx-xxxx)*
Internet Address
Contact Person & Title*
Contact Person E-Mail
Email *
Person(s) Authorized to Sign Quotes, Bids and / or Contracts (list additional names below)*
Additional "Authorized" Names
Additional "Authorized" Names
Type of Organization*	Sole Proprietorship Partnership Joint Venture Indiana Corporation Corporation Medical Corporation Other - please answer next question
If you selected "Other" in the previous question, please list the type of business here.
Number of Years in Current Business*
Ownership and Control of Company (check all that apply)*	For purposes of this registration, "owned and controlled" means having: 1. ownership of at least fifty-one percent (51%) of the enterprise, including corporate stock of a corporation; 2. control over the management and active in the day-to-day operations of the business; and 3. an interest in the capital, assets and profits and losses of the business proportionate to the percentage of ownership. United States Citizen African American Hispanic American Indian Asian American Woman Disadvantaged
If MBE, WBE or DBE Ownership Certified via: (check all that apply)*	City of Indianapolis, Division of Equal Opportunity State of Indiana, Department of Administration Other - please answer next question Not Certified
If you selected "Other" in the previous question, please list certification type.
Type of Business (check all that apply)*	Auto Supplies Cellular Phones / Pagers Computer Service / Repair Computer Supplies / Equipment Drugs / Medicines Educational Materials Heating, A/C, Refrigeration Janitorial Services / Supplies Lab Supplies Medical Supplies Office Equipment / Furniture Office Equipment Repair Office Supplies Printing Advertising Publications Other - please answer next question
If you selected "Other" in the previous question, please list the type of business here.