Thank you for your interest in serving North Carolina's community health centers through our Group Purchasing Organization. Before completing this application, please review the GPO Vendor Information Package.

At the end of the application, you will be prompted to pay the $175 application fee electronically by credit card or by mailing a check.

Contact:
Chris Shank
Vice President of Operations and Development
North Carolina Community Health Center Association
919-297-0012
shankc@ncchca.org

Question Title

* 1. Company Name

Question Title

* 2. Company Website

Question Title

* 3. Contact Person Name

Question Title

* 4. Contact Person Title

Question Title

* 5. Contact Person Email

Question Title

* 6. Contact Person Phone

Question Title

* 7. What category of goods and services does your company offer? (check all that apply)

T