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
*Required Field