Vendor Registration

Join a select and elite team of Samaritan trusted vendors.

Organization/Business Name(Required)

Company Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Website Address(Required)

Point of Contact(Required)

First Last

Phone Number (Day)(Required)

Phone Number (Evening)(Required)

24/7 E-mail(Required)

General Description of Services(Required)

Establishment Date(Required)

Geographic Service Area(Required)

Service Offerings(Required)

Agency Licensed?(Required)

Yes

No

Agency State License Number(Required)

General Liability & Workers Compensation Insured?(Required)

Yes

No

Agency Security License(Required)

Max. file size: 512 MB.

Certificate of Insurance(Required)

Max. file size: 512 MB.

Capabilities Statement(Required)

Max. file size: 512 MB.

Signed W9 Form(Required)

Max. file size: 512 MB.

Date(Required)

Company Representative Signature(Required)

Please type your name to indicate your signature