GLN Registry for Healthcare® Signup Application

 
This Agreement is a contractual agreement to subscribe to the GLN Registry for Healthcare. Once the application has been completed and payment received, further information will be provided to you regarding the steps to register your GLN(s) within the Registry.

Not all business entities can subscribe to the Registry. Market Research companies cannot join at this time. The Registry cannot be resold in whole or in part. An entity subscription can be withdrawn by GS1 US at any time for breach of the agreement.

 
* Applicant First Name: * Applicant Last Name:
* Company Name: Doing Business As:
GLN: * Applicant Job Title:
* Applicant Email: * Confirm Email:
 
GPO Referral: Select all those that apply (hold down the CTRL Key) to make multiple selections.
Company Address    
* Phone : Fax :
* Address 1:
Address 2:
* City : * State/Province :
* Postal Code : * Country :
Billing Contact
* First Name: * Last Name:
* Phone: * EMail:
System Administrator Contact
Same as Billing
* First Name: * Last Name:
* Phone: * EMail:
 
* Company Type
GPO     Healthcare Provider     Wholesaler/Distributor     Manufacturer     Solution Provider
 
* Primary Line of Business
Please select all those that apply, You may make multiple selections by holding down the CTRL Key and selecting with your mouse.
 
     * Company is a current 1Sync Subscriber  Yes  No
     * Annual Sales Revenue: $  (USD)