Vendor Program Application

• Name of Provider
• Federal ID Number
• Years in Business
• Name of Authorized Agent
• Title of Authorized Agent
• Telephone Phone
• Email Address

• Address
• City
• State
• Zip

• Address
• City
• State
• Zip

• Discounted Product or Service Offered (in 75 words or less)
• Amount of Discount
• If other, please explain
• Special Instructions or Limitations (in 75 words or less)
• Discount Web Site (if applicable)
• Discount Code (if applicable)
• Is the business related in any way to any UT System or UTHealth officers or employees?
  • Yes
  • No

By submitting this form, the provider acknowledges and agrees with the provisions of the UTHealth Vendor Agreement and certifies that the information provided in this form is true and correct.

Enter the full name of provider (or authorized agent) below.

• Authorized Agent
• Date

• I am a spam bot(If you are a human, do not check this box)