Supplier Registration

(* = Required) Date: 7/3/2009

If you have already completed a Supplier Registration form Click Here to Login.
The username and password allow suppliers to review and update profiles in order to keep it up to date. Usernames and passwords must each be at least 4 characters in length and are required.
* Username:
* Password:

General Company Information

Are you currently doing business with Humana as a supplier?
Yes No Contact:
Are you currently doing business with Humana as a customer?
Yes No
Description of Product/Service to provide:
* Full Legal Company Name
* Company Address
* City
* State
* Zip
* County
Country
Company Homepage (www.companyname.com)
* Year Established (YYYY):
* Number of Employees
* Point of Contact Name (Last, First)
* Point of Contact Title
* Point of Contact E-Mail Address
* Telephone # (XXX-XXX-XXXX):
* Fax # (XXX-XXX-XXXX):
* Federal Tax ID # (XX-XXXXXXX):
Dun & Bradstreet # (XX-XXX-XXXX):
Primary SIC #:
Primary NAIC #:

Primary category for Product/Service provided?:
Business Structure:
Service Territory:	Local Regional National International

Major industries served:	Health Care Svcs Manufacturing Construction Retail Transportation Wholesaling Other

Ownership Information

Ownership Classification/Ethnicity
(select all that apply by using the Ctrl key while clicking):

Ownership Certifications:	Check any/all that apply:
	National Minority Supplier Development Council (or affiliates)
	Women's Business Enterprise National Council (or affiliates)
	Small Business Administration
Other

Do you use and track minority subcontractors?

Yes No

Customer Focus Information

Do you have a customer accounting for > 10% of your sales?	Yes No Explain:
Services - Does your company utilize service-level agreements (SLAs)?	Yes No Explain:
Products - Do you have written EHS (Environmental Health & Safety) policies posted for all employees?	Yes No Explain:
What % of your good or services are delivered on time?
Technical capabilities:	Other:

Legal Information

Does your company have any leins, judgements, or pending law suits over $500,000? If yes, briefly describe.

Yes No
Explain:

Financial Information

Annual Sales
Will you provide a copy of your company's published annual report and/or a financial statement for the last three years?	Yes No Explain:

BY SUBMITTING THIS FORM, I CERTIFY THAT THE INFORMATION IS ACCURATE. A REPRESENTATIVE OF OUR COMPANY WILL PROVIDE UPDATES IF THE INFORMATION PROVIDED SHOULD CHANGE.