Vendor Liaison Office UW Hospital and Clinics G5/140, M/C 1639 600 Highland Avenue Madison, WI 53792 Phone: 608-890-8505 Fax: 608-890-8507 VENDOR REPRESENTATIVE REGISTRATION FORM Application Date / / REPRESENTATIVE INFORMATION Name Title Preferred Mailing Address City, State, Zip Work Phone # Mobile Phone # E-mail REPRESENTATIVE’S IMMEDIATE SUPERVISOR Name Title Preferred Mailing Address City, State, Zip Work Phone # Mobile Phone # ___________________________ mail COMPANY Name of Company Headquarters Address City, State, Zip Company Main Phone # Company Web Address
Vendor Liaison Office UW Hospital and Clinics G5/140, M/C 1639 600 Highland Avenue Madison, WI 53792 Phone: 608-890-8505 Fax: 608-890-8507 VENDOR REPRESENTATIVE REGISTRATION FORM Application Date / / REPRESENTATIVE INFORMATION Name Title Preferred Mailing Address City, State, Zip Work Phone # Mobile Phone # E-mail REPRESENTATIVE’S IMMEDIATE SUPERVISOR Name Title Preferred Mailing Address City, State, Zip Work Phone # Mobile Phone # ___________________________ mail COMPANY Name of Company Headquarters Address City, State, Zip Company Main Phone # Company Web Address
vlo_registration.docx