Supplier Add FormPage 1EXTERNAL – Supplier Information Supplier Name Initial Date WebsiteSupplier Main Address Address Line 1 Address Line 2 City Postal/Zip Code CountryPlease select…AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos ( Keeling ) IslandsColombiaComorosCongoCook IslandsCosta RicaCôte d ‘ IvoireCroatia ( Hrvatska )CubaCyprusCzech RepublicCongo ( DRC )DenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands ( Islas Malvinas )Faroe IslandsFiji IslandsFinlandFranceFrench GuianaFrench PolynesiaFrench Southern and Antarctic LandsGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong SARHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SARMacedonia, Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSamoaSan MarinoSão Tomé and PrìncipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSt. HelenaSt. Kitts and NevisSt. LuciaSt. Pierre and MiquelonSt. Vincent and the GrenadinesSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaViet NamVirgin Islands ( British )Virgin IslandsWallis and FutunaYemenZambiaZimbabwe Province/State Phone # Office Fax #Supplier Remit to Address (if different from main address) Address Line 1 Address Line 2 City Postal Code CountryPlease select…AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos ( Keeling ) IslandsColombiaComorosCongoCook IslandsCosta RicaCôte d ‘ IvoireCroatia ( Hrvatska )CubaCyprusCzech RepublicCongo ( DRC )DenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands ( Islas Malvinas )Faroe IslandsFiji IslandsFinlandFranceFrench GuianaFrench PolynesiaFrench Southern and Antarctic LandsGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong SARHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SARMacedonia, Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSamoaSan MarinoSão Tomé and PrìncipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSt. HelenaSt. Kitts and NevisSt. LuciaSt. Pierre and MiquelonSt. Vincent and the GrenadinesSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaViet NamVirgin Islands ( British )Virgin IslandsWallis and FutunaYemenZambiaZimbabwe ProvincesPlease select…AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Main Office Phone # Main Office Fax #INTERNAL DistributionFull Franchise (51)Continuing Care (81)MDS (82)DND (81-88)Stockless (91)Cardinal (72-75) Cardinal Private Label SupplierYesNo Cardinal-CareFusion Selling Division 64/65YesNo Cardinal-CareFusion Div 42-25YesNo FutureMedYesNo DisMedYesNo PL BrandsYesNoPage 2EXTERNAL- Purchasing/Order Processing Data Purchasing Contact Phone Email Main Office Phone # Main Office Fax # EDI CapabilityYesNoAdditional Order Information Order Minimum Ordering Time (Calendar Days) Estimated Annual Purchase Product Type Standard Lead TimeReturn Policy and ContactSpecify 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) CommentsINTERNAL- Purchasing/Order Processing Data Service LevelPlease select…NoneOrder to BackorderNormal (95%)Exceptional (>95%) Initial Stocking DCPlease select…11 Moncton12 Mount Pearl NFLD20 Dorval24 QC JIT STOCKLESS25 QC JIT STOCKLESS31 National Technic34 NSC37 JIT STOCKLESS43 Cardinal Health VIP44 Pt. Claire Capital/Haz51 Winnipeg73 Edmonton81 BurnabyAdditional Freight Information IncotermsPlease select…NoneCOL – CollectCOX – Collect with CrosPPA – Prepaid & AddPPB – Prepaid & BillPPT – PrepaidPPX – Prepaid with Cros Estimate Freight Factor % Carrier Choice Shipment Size (if collect)Return Policy and ContactSpecify 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) Buyer Name CommentsPage 3EXTERNAL- Inbound Transportation Traffic Manager Phone Email Tax ID Number (Outside of Canada Only) Do you have the ability to ship direct to customers?YesNo Do you have the ability to ship to other distribution centres besides our main distribution centre in Mississauga?YesNoDimensions & 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…217381 Country of Export CSA SupplierINTERNAL- Inbound Transportation Total Annual Transportation Cost Carrier Choice Transit Time Freight FactorPage 4EXTERNAL – Customs Preferred Specialized Vendor’s ContractCustomsGlobal TradeExport/Imports Country of Export VFD Code Custom Broker Name Custom Broker Email Custom Broker Phone Account #Page 5EXTERNAL- Accounts Payable Data Finance Contact Phone EmailPayment Information Payment TermsPlease select…Net 10Ne 10 & DiscountNet 15Net 15 & DiscountNet 20Net 20 & DiscountNet 30Net 30 & DiscountNet 60Net 60 & DiscountNet 90Net 90 & Discount2% 30/net 602% 15 NET 602% 15 NET 30 Days2% 30 NET 312% 30 NET 60shows P-cardshows BIP-CARDOther Other (if selected) CurrencyCADUSD Budget FX CodePlease select…CACCATUSCUSTUSPNTCOther Other (if selected) G/L ClassIAPUSANTCINTERNAL – Accounts Payable Data Document TypeOPOUOCPage 6Regulatory Affairs/Quality Assurance Data RA/QA Contact Phone EmailProduct Information Product Description Product ClassPlease select…ChemicalClass 1 Medical DeviceClass 2 Medical DeviceClass 3 Medical DeviceClass 4 Medical DeviceDrug Tray ProductFoodOther Other Product Class (Please Specify)Please select…ChemicalClass 1 Medical DeviceClass 2 Medical DeviceClass 3 Medical DeviceClass 4 Medical DeviceDrug Tray ProductFoodOther Special HandlingPlease select…NoneTDGWHMISMSDSOther Other (if selected) Special CertificationPlease select…NoneCMDCAS CertificationDrug Certification (DIN)ISO CertificationOther Other (if selected)Additional Information Health Canada Company ID Regulatory Vendor TypePlease select…D – DistributorF – FabricatorFD – Fabricator andFM – Fabricator andM – ManufacturerMD – Manufacturer andNM – NON MedicalS – Service ProviderPage 7CARDINAL HEALTH – Marketing Data Marketing Contact Phone Email Vendor Manual ConfirmationSUPPLIER – Vendor Manual I have agreed that I have reviewed and approved the vendor manualYesNo
