Fillable SUPPLIER INFORMATION vendorsetup@uchicago.edu (773) 702-5800 (University of Chicago)

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SUPPLIER INFORMATION vendorsetup@uchicago.edu (773) 702-5800 (University of Chicago)

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SUPPLIER INFORMATION
vendorsetup@uchicago.edu
(773) 702-5800
ZIP Code*
State*
Email*
MAIN ADDRESS / CONTACT INFORMATION
Company Name*
Street Address*
Country*
City*
Phone #*
Website (URL)
BUSINESS CLASSIFICATION
Minority Business Enterprise*
Yes
No
Woman-Owned*
Business Enterprise
Yes
No
PRODUCT INFORMATION
Commodity Type*
Products/Services*
Software Supplier
Yes
No
Software Location Desktop
Network
Software Description
License Type Individual Multi-User Network
Other
Access to Personal Health
Information?*
Yes
No
Explain your Access to PHI
or Provide Additional Comments
SIGNATURE
By checking the box below, I acknowledge the information provided is accurate, may be used by the University for
informational purposes, and does not guarantee any work or business.
Agreed to:*
If your commdity or products/services are related to "Information Technology" please complete the selection below.
Name* Position*
Phone #* Email*
(*) indicates required fields
6/23/2015 1
Submit
BACK OFFICE ONLY
Status
11/29/2018
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SUPPLIER INFORMATION vendorsetup@uchicago.edu (773) 702-5800 (University of Chicago)

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Completed 10 February 2021

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