GPO Registry

GPO

Automatically Logged (not editable)

Facility Name:*

Legal Name of Entity

Member ID :*

GPO Membership Number

Tax ID *

Your Tax Identification Number

Street Address*

Facility Address

Street Address - Line 2

City*

State*

ZIP*

Contact Name*

The day to day contact for the facility

Phone Number:*

Main Phone Number of the Facility

Email Address:*

Main Email address

Domain Name:*

Company's domain name

Affiliate GPO

Affiliate GPO organization requesting AT&T discount

Affiliate GPO Contact

AT&T's contact for the Affiliate GPO

Phone Number

Affliliate GPO contact's phone number

Email Address

Affiliate GPO contact's email address

AM:

GPO Account Manager

RSM:

GPO Regional Sales Manager

Special Instructions

Enter code*

*Required Field