Outline Agreement Form

Arkansas Department of Health Procurement/Support Branch

Agency Name(Required)

Contact Name(Required)

First Last

Email(Required)

Phone Number

Fax Number

Authorized Representative

By checking this box, you confirm you are an authorized representative for you agency.(Required)

Confirm

Date

Agency Delivery Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please check if Invoice Address is same as Delivery Address.

Yes, send the invoice to the delivery address.

Agency Invoice Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Supplier AASIS Vendor Number (Vendor)

Supplier Name

Supplier Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please check if Remittance Vendor is same as Supplying Vendor

Confirm

Remittance AASIS Vendor Number (Partner Vendor)

Remittance Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

AASIS Outline Agreement/State Contract Number

Validity Begins

Validity Ends

Total Cost

Report Category(Required)

Item Description

Quanity

Unit Price

Unit of Measure

Total

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