Provider Profile Form

To join our empactMarketplace as a provider, please complete the following on-line form and submit it by pressing the Send button at the end of the form. We will send you a username and password in the near future after processing your information.

Organization Information
Organization Name:
Address:
City:
State/Province:
Zip/Postal Code:
Country:
Phone:
Fax:
Website Address (URL):

Contact Information
Name Phone E-mail
President / CEO:
Primary Contact:
Materials Manager Contact:
Information Technology Contact:
e-Commerce Contact:

General Statistics
Beds in Operation: Physicians Employed:
Annual Revenues: Physicians on Staff:
Annual Adjusted Patient Days: Materials Management FTE's:
Number of Facilities: Fiscal Year:

Procurement Information
Most Recent Annual Expense Budget
Medical Supplies:
Capital Equipment:
Services:
Totals:
How many PO's do you receive annually?
How many items (for purchase) do you process annually?
Do you have a digital source listing all of your items? Yes No
What % (estimate as necessary) of your occurs via the following sources?
Phone: % EDI: % OBL: %
Mail: % E-mail: % Web: %
Fax: % XML: % Other: %
Please list your distributors:
Please list all group purchasing organizations with which you are affiliated and your estimated contract compliance for each:
GPO Contract Compliance
%
%
%
%

Information Technology
General Ledger System:
Accounts Payable System:
Material Management/Inventory Management System(s):
Interface Engine:
ERP (Enterprise Resource Planning System):
Primary Computer Hardware
Computer Operating System
Windows NT UNIX
Other (please explain)   
Do you plan on changing any of your current IT systems over the next two years? Yes No
If so, please describe:
Does your company have an internal intranet? Yes No
An external extranet?
Yes No    Explain
Approximately how many of your employees have access and/or authorization to use the Internet?
All over 50%
25%-50% under 25%
What type of electronic commerce initiatives are you currently involved in?

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