Supplier Add Form Page 1 Supplier Information Supplier Name Initial Date Source Account # Website Distribution Full Franchise (51) Continuing Care (81) MDS (82) DND (81-88) Stockless (91) Cardinal (72-75) Supplier Buy-from Address Address Line 1 Address Line 2 City Postal/Zip Code CountryPlease select… Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos ( Keeling ) Islands Colombia Comoros Congo Cook Islands Costa Rica Côte d ‘ Ivoire Croatia ( Hrvatska ) Cuba Cyprus Czech Republic Congo ( DRC ) Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands ( Islas Malvinas ) Faroe Islands Fiji Islands Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao SAR Macedonia, Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Samoa San Marino São Tomé and Prìncipe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Kitts and Nevis St. Lucia St. Pierre and Miquelon St. Vincent and the Grenadines Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Viet Nam Virgin Islands ( British ) Virgin Islands Wallis and Futuna Yemen Zambia Zimbabwe Province/State Phone # Office Fax # Cardinal Private Label SupplierYesNo Cardinal-CareFusion Selling Division 64/65YesNo Cardinal-CareFusion Div 42-25YesNo FutureMedYesNo DisMedYesNo PL BrandsYesNo Supplier Remit to Address (if different from main address) Address Line 1 Address Line 2 City Postal Code CountryPlease select… Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos ( Keeling ) Islands Colombia Comoros Congo Cook Islands Costa Rica Côte d ‘ Ivoire Croatia ( Hrvatska ) Cuba Cyprus Czech Republic Congo ( DRC ) Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands ( Islas Malvinas ) Faroe Islands Fiji Islands Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao SAR Macedonia, Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Samoa San Marino São Tomé and Prìncipe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Kitts and Nevis St. Lucia St. Pierre and Miquelon St. Vincent and the Grenadines Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Viet Nam Virgin Islands ( British ) Virgin Islands Wallis and Futuna Yemen Zambia Zimbabwe ProvincesPlease select… Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Main Office Phone # Main Office Fax # Page 2 Purchasing/Order Processing Data Purchasing Contact Phone Email EDI CapabilityYesNo Additional Order Information Order Minimum Ordering Time (Calendar Days) Manufacturing Time Service LevelPlease select… None Order to Backorder Normal (95%) Exceptional (>95%) Product Type Initial Stocking DCPlease select… 11 Moncton 12 Mount Pearl NFLD 20 Dorval 24 QC JIT STOCKLESS 25 QC JIT STOCKLESS 31 National Technic 34 NSC 37 JIT STOCKLESS 43 Cardinal Health VIP 44 Pt. Claire Capital/Haz 51 Winnipeg 73 Edmonton 81 Burnaby Main Office Phone # Main Office Fax # Return Policy and Contact Specify instructions for return in the comments section: (i.e. Maximum Time/Quantity and restock fee for: Regular Return / Damage Goods / Quality Issues / Expired Products or About to Expire Products) Contact (if different) Buyer Name Comments Page 3 Inbound Transportation & Customs Traffic Manager Phone Email Tax ID Number (Outside of Canada Only) Additional Freight Information Freight TermsPlease select… None COL – Collect COX – Collect with Cros PPA – Prepaid & Add PPB – Prepaid & Bill PPT – Prepaid PPX – Prepaid with Cros Estimate Freight Factor % Carrier Choice Shipment Size (if collect) Dimensions & Weight Dimensions of STD Product (LxWxH)incm (L) (W) (H) Weight of STD Product lbskg Weight Cost of STD Product CADUSD Cost Shipping Estimated Lead Time Shipping Origin Cross DockYesNo Cross Dock RegionsPlease select… 21 73 81 Country of Export CSA Supplier VFD Code Page 4 Accounts Payable Data Finance Contact Phone Email Payment Information Payment TermsPlease select… Net 10 Ne 10 & Discount Net 15 Net 15 & Discount Net 20 Net 20 & Discount Net 30 Net 30 & Discount Net 60 Net 60 & Discount Net 90 Net 90 & Discount 2% 30/net 60 2% 15 NET 60 2% 15 NET 30 Days 2% 30 NET 31 2% 30 NET 60 shows P-card shows BIP-CARD Other Other (if selected) CurrencyCADUSD Document TypeOPOUOC Budget FX CodePlease select… CAC CAT USC UST USP NTC Other Other (if selected) G/L ClassIAPUSANTC A/P RepPlease select… Ivana Banjsak Gabriela Murgan Fatima Rajakariar Rina Pierri Valentyna Park Other Other (if selected) Page 5 Regulatory Affairs/Quality Assurance Data RA/QA Contact Phone Email Product Information Product Description Product ClassPlease select… Chemical Class 1 Medical Device Class 2 Medical Device Class 3 Medical Device Class 4 Medical Device Drug Tray Product Food Other Other Product Class (Please Specify)Please select… Chemical Class 1 Medical Device Class 2 Medical Device Class 3 Medical Device Class 4 Medical Device Drug Tray Product Food Other Special HandlingPlease select… None TDG WHMIS MSDS Other Other (if selected) Special CertificationPlease select… None CMDCAS Certification Drug Certification (DIN) ISO Certification Other Other (if selected) Additional Information Health Canada Company ID Regulatory Vendor TypePlease select… D – Distributor F – Fabricator FD – Fabricator and FM – Fabricator and M – Manufacturer MD – Manufacturer and NM – NON Medical S – Service Provider Page 5 Marketing Data Marketing Contact Phone Email Supplier ReviewYesNo Review Cost PolicyYesNo Price Information List Price MethodPlease select… None Supplier List TM/List Program TM Min Price % List Price % Product Manager
