Business Name *

First Name *

Last Name *

Role * CEO / President Executive / VP Director / Manager Staff / Individual Contributor Supplier Rep Other

Department * Administrative Clinical/Medical Compliance Dental Facilities Finance Food Human Resources IT Lab Operations Other Pharmacy Supply Chain

Job Title *

Email *

Phone *

Class of Trade * Physicians Community Health Center / Free Clinic Surgery Center Non-Healthcare Free Standing Lab Assisted Living Other

Business Street Address *

Business City *

Business State *

Business Zip Code *

Number of Locations *

How many full time employees does your organization have? *

How Did You Hear About CNECT? * Supplier Referral - McKesson Supplier Referral - Quest Supplier Referral - Other Medical Association Member Referral Other Social Media Trade Show Webinar Website

Supplier Rep Name *

Supplier Rep Email *

Would you like to be connected to GPO pricing through McKesson? * Yes No

McKesson Account Number *

McKesson Representative *

McKesson Rep Email *

What contracts would you like more information on? (Select all the apply) * Medical Supplies & EquipmentPharmaceutical SuppliesReference Lab ServicesOffice Supply SolutionsFood Purchasing ServicesInbound & Outbound Shipping ServicesMedical Waste Disposal & ShreddingFacilities & Environmental ServicesIT Equipment & ServicesCredit Card Processing Services

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