Premier Group Purchasing Organization enrollment form – Premier and Meals on Wheels America

Confirmation

Please confirm that you are a Meals On Wheels America participant by checking the box below before continuing.*

Our organization provides meals and/or services to seniors

Contact information

Name*

First Last

Title*

What is the title of your role / job at your organization?

Email address*

Enter Email Confirm Email

Phone number*

FAX

Account information

Organization name (participating member)*

Federal Tax / Employee Identification No. (TIN/EIN)

Address*

Street Address City State ZIP Code

Phone number*

FAX

Organization type

Meals on Wheels Service Provider?*

Yes.

Confirm your organization provides Meals on Wheels services.

Are you a healthcare provider (i.e., receiving Medicare and/or Medicaid funding)?

Healthcare provider*

Yes
No

If you are a healthcare provider and/or receive Medicare and/or Medicaid funding select "yes" to the left and download, complete, sign and submit a Facility Authorization & Vendor Fee Agreement ("Exhibit A") to premierreach@premierinc.com. Otherwise, select "no".

Food purchasing

If you are interested in the Meals On Wheels / Premier Foodservice program please provide the following information:

Estimated Annual Foodservice Purchases: $

Current Foodservice Distributor(s)

Average Daily Sales Outstanding (account payable terms)

Scheduled Food Deliveries Per Week

Average Food Drop Size: $

Are you interested in other contract categories?

Check all that apply.

Office supplies
Copiers / print services
Background checks
Janitorial supplies
Furniture
Facilities / construction
Foodservice equipment
Other

Please specify.

Additional ship to locations or sites

If your agency has multiple locations that would access any or all of the GPO contracts, please download and complete this spreadsheet template ("Schedule 1") and email it to Premier to ensure that they are linked to the program.

Terms and conditions

I agree to the Terms and Conditions of participation on behalf of the Participating Member and all facilities listed on Schedule 1.

I agree to the terms and conditions*

Yes

The individual who submits this form on behalf of the Participating Member represents and warrants that he/she is duly authorized to bind the Roster Participant to the Terms and Conditions of Participation as indicated above.