DELTA PURCHASING ALLIANCE MEMBER PARTICIPATION AGREEMENT
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Month
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Day
Year
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Health Center Name (Member Details)
Organization Name
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Organization Name2
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Organization Name3
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Organization Name4
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Organization Name5
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Organization Name6
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Organization Name7
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First Name
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Last Name
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First Name2
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Last Name2
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First Name3
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Last Name3
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First Name4
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Last Name4
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First Name5
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Last Name5
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Title
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Title2
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Title3
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Title4
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Email
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example@example.com
Phone
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Fax
Address
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Street Address
Street Address Line 2
City
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Postal / Zip Code
Address2
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Street Address
Street Address Line 2
City
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Address3
*
Street Address
Street Address Line 2
City
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Postal / Zip Code
Address4
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PARTICIPANT
Print Name of Person Signing
Print Name of Person Signing2
Print Name of Person Signing3
Title of Person Signing
Title of Person Signing2
Title of Person Signing3
Date Signed
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Month
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Day
Year
Date Signed2
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Month
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Day
Year
Address
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Street Address
Street Address Line 2
City
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Date Signed3
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Month
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Day
Year
Date Signed4
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Month
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Day
Year
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Date Signed5
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Participation Agreement
Please Select and Sign
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DELTA PURCHASING ALLIANCE MEMBER PARTICIPATION AGREEMENT
MCKESSON MEDICAL-SURGICAL DESIGNATION FORM
GPO DESIGNATION FORM
PROVISTA GPO PARTICIPATION AGREEMENT
DELTA PURCHASING ALLIANCE MEMBER PARTICIPATION AGREEMENT
MCKESSON MEDICAL-SURGICAL DESIGNATION FORM
GPO DESIGNATION FORM
PROVISTA GPO PARTICIPATION AGREEMENT
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