Vendor Information Form - National EMR

Vendor Information Form

National EMR will be transitioning to a new procurement system in September 2024. Please fill out the form below so we can set you up as a vendor in our new system. Please reach out with any questions or concerns to AccountsPayable@NationalEMR.us.

*If we have more than one account active with your company, please complete a form for each account.

Vendor Information Form

Business Information

Business Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Additional Information

Name

Phone Number

Fax Number

Email

Website

Tax ID Number

Reference Number used in Vendor's System (Account or Customer Number)

Accounts Receivable Contact

Name

Job Title

Email

Business Phone Number

Cellphone Number

Accounts Receivable Contact