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CITY OF SAN BER.RDINO -
REQUEST COR COUNCIL ACTION
From: ANNIE F. RAMOS. DIRECTOR
Dept: PARKS. RECREATION & COMMUNITY SERVICES
Date: MAY 11. 1994
RESOLUTION AUTHORIZING THE DIRECTOR OF
Subject: PARKS. RECREATION AND COMMUNITY SERVICES
DEPARTMENT TO EXECUTE AN AGREEMENT WITH
THE CENTER OF HEALTH RESOURCES PURCHASE
CONNECTION. GROUP PURCHASING. DIETARY
PROGRAM FOR RAW FOOD PRODUCTS FOR THE
rTTY'~ ~FNTOR NIITRTTTON PROGRAM
Synopsis of Previous Council action:
Similar agreements have been in effect since July 1986.
Recommended motion:
Adopt the resolution.
L7~
Signature
Contact person: John A. Kramer
Phone: 5031
Supporting data attached: Staff Report. Resol ution & Agreement Ward:
City-Wi de
FUNDING REQUIREMENTS:
Amount:
N/A
Source: (Acct. No.) No Ci ty Funds I nvo 1 ved.
(Acct. Description)
Finance:
Council Notes:
75-0262
Agenda Item No. 7
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CITY OF SAN BERNODINO - REQUEST FOR COUNCIL ACTION
STAFF REPORT
RESOLUTION AUTHORIZING THE
DIRECTOR OP PARKS, RECREATION
AND COMMUNITY SERVICES DEPARTMENT
TO EXECUTE AN AGREEMENT WITH THE
CENTER OP HEALTH RESOURCES
PURCHASE CONNECTION, GROUP PURCHASING,
DIETARY PROGRAM POR RAW POOD
PRODUCTS POR THE CITY'S SENIOR
NUTRITION PROGRAM.
The Senior Nutrition Program of the City of San Bernardino
spends eighty percent (80%) of its annual raw food budget
($191,000) with those vendors who are members of the Purchase
Connection. In return, the Purchase Connection rebates two
percent (2%) of the gross purchase cost to the City of San
Bernardino Nutrition Program. The Senior Nutrition Program
pays the Purchase Connection .015 or 1/2 cents per meal
served, estimated to be $1,745 for 1994-95, to take advantage
of its group purchasing program. In addition to the rebates
through the Purchase Connection, significant savings are
realized annually through utilization of those vendors
recommended by the Purchase Connection.
Use of the Purchase Connection essentially serves as a buying
"Co-op," and provides substantial savings both in direct food
costs as well as staff time. Municipal Code MC-858,Section
3.0.04.010, Paragraph B.3. authorizes this type of purchase
arrangement.
purchase connection grp
5/11/94
75-0264
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RESOLUTION
RESOLUTION AUTHORIZING THE DIRECTOR OF PARKS, RECREATION AND
COMMUNITY SERVICES DEPARTMENT TO EXECUTE AN AGREEMENT WITH THE
CENTER OF HEALTH RESOURCES PURCHASE CONNECTION, GROUP PURCHASING,
DIETARY PROGRAM FOR RAW FOOD PRODUCTS FOR THE CITY'S SENIOR
NUTRITION PROGRAM.
BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF THE CITY
OF SAN BERNARDINO AS FOLLOWS:
SECTION 1.
The Director of Parks, Recreation and
Community Services is hereby authorized and directed to execute
on behalf of said City an agreement with the Center of Health
Resources Purchase Connection, G~oup Purchasing, Dietary Program
relating to the reduced purchasing price of raw food products for
the City's Senior Nutrition Program. A copy of said agreement is
attached hereto, marked Exhibit "A" and incorporated herein by
reference as fully as though set forth at length.
SECTION 2.
The authorization granted hereunder shall
expire and be void and of no further effect if the agreement is
not executed by both parties and returned to the office of the
City Clerk within 60 days following the effective date of the
resolution.
I HEREBY CERTIFY that the foregoing resolution was duly
adopted by the Mayor and Common Council of the City of San
Bernardino at a
meeting thereof, held on the
day of
, 1994 by the following vote, to
wit:
II
II
II
5/11/94
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RE: RESOLUTION REGARDING AN AGREEMENT WITH CENTER OF HEALTH
RESOURCES PURCHASING CONNECTION, GROUP PURCHASING, DIETARY
PROGRAM FOR THE CITY'S SENIOR NUTRITION PROGRAM.
COUNCIL MEMBERS
AYES
NAYS
ABSTAIN
NEGRETE
CURLIN
HERNANDEZ
OBERHELMAN
DEVLIN
POPE-LUDLAM
MILLER
ABSENT
Rachel Clark, City Clerk
The foregoing resolution is hereby approved this
day of
, 1994.
Tom Minor, Mayor
City of San Bernardino
Approved as to form
and legal content:
James F. Penman
City Attorney
By:
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purchase connection grp-u
5/11/94
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PURCHASgJ, lfO~ECTION~
/1/III11I11/11'''''.T r."'Um"""III1I1f111
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SENIOR NUTRITION PRO~ CENTER OF HEALTH RESOURCES
. 201 North Figueroa Street
GROUP PURCHASING DIETARY PROGRAMAngetes. CA 90012
, (213) 250-5600
FEE SCHEDULE Fax: t213} 250-4863
Purchase Con. ?ction will provide Senior Nutrition Proorams the benefits of
Agreements Purchase Connection has negotiated with dietary vendors. The strength
of this program and its savings have been obtained through a high de9ree of
membership commitment and utilization of the program; . Both Hospitals and Senior
Nutrition Programs are required to purchase at least 60% of dietary supplies needed
by them and available under Purchase Connection Agreements through this program.
Soft Drinks,
Groceries (including paper) and frozen Foods,
Meat (fresh and frozen). Bread, Produce.
Coffee, Eggs, Detergent, Fountain
Dairy, Enteral Nutrition.
Senior Nutrition Programs may choose from two methods of billing for this service.
It should be noted that the cents per meal rate aids in budgeting as well as a 'cap'
on the expense for the Projects.
PRODUCTS AVAILABLE:
x
.015 cents per meal served as
reported monthly by programs
2% of purchases reported
monthly by suppliers
Initial
Initial
Billing will be monthly. Minimum fee is $75.00
The terms of this Agreement will be effective
July I, 1994 - June 30, 1995
Signature below will indicate acceptance of the above.
City of San Bernardino
Senior Nutrition Program Name
547 No. Sierra Way
Address
San Bernardino, CA 92410
ACCEPTED FOR PROGRAM
Date
Project Director
10/91
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PURCHAStllfONNECTlON(!\
I/I/III/"''''''''''-T r-",,,,,,,,,m"lIlIllll
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@~ CENTER OF HEALTH RESOURCES
. 201 North Figueroa Street
Los Angeles. CA 90012
(213) 250-5600
Fax: (213) 250-4863
GROUP PURCHASING, DIETARY PROGRAM
PURCHASING COMMITMENT
EXTENDED CARE FACILITIES
. RETI.REMENT HOMES
(Based on licensed Beds)
AND
SENIOR NUTRITION PROGRAMS
(Based on Meals Served)
City of San Bernardino Senior Nutrition Program
reported an average
of
300
meals served per day.
In computing your commitment to purchase through Purchase Connection, Dietary
Program, the following statistical steps have been taken:
300
Meals
X 30 days = g,OOO
Meals per month
9,000
Meals
per month X $1.00 (estimated raw food cost per meal)
= $ 9,000
X 60% (Percentage of total non - labor dietary costs required for
commitment) = $5,400.00
Your facilities commitment is to purchase $ 5,400.00
approved vendors.
per month through the
11/93
comm.frm
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PURCHASg"J /lEONNECT/ON@
1I11111111111"""'.T ,-."'""1111/11111111/111
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@~ CENTER OF HEALTH RESOURCES
. 20 1 North Figueroa Streel
COHR-CONNECTION Los Angeles. CA 90012
(213) 250-5600
PURCHASE CONNECTION Fax: (213) 2$-4863
PARTICIPATION AGREEMENT
TIDS AGREEMENT made 011 ,199-1 is belWeeO CORR-CONNBCTION (bereinafter .CORR.
or "CORR-CoDDectioa.), a CaliComia Corpondioa, bavinl il.l priDcipal place oC business at 201 Nonb Figueroa
Aveoue, 4th Floor, Los Angeles, CaliComia. 90012-2623, and
. (bereinafter "Participalinl Member" or "Member")
wbose principal place oC business is located at
WHEREBY the Participalinl Member desiJes to elllU inlo Ihis ApeemeDC Cor the purpose oCparticipating in COHR-
Conoectioa oeaotiated pvup pun:basiDa apeenteDlS iDvolviDa the purchase oC bealth caze supplies aDd equipmelll
solely Cor its .0Ml use..
WHEREfORE the PartieipaliDl Member speciflc:al1y apees to abide by Illd be ob1iaaled UDder Ibe CoUowina lenns
aDd CoaditiODl set Corlb below: -
I. ACCESS TO GROUP PURCHASING AGREEMENTS
Provided there bas beeD DO expintiOll, tenniDalioa or Olber violatioD or bJaCb of Ibis Acmmeot, the Puticipatina
Member sba1l be eDlided 10 pun:bae beallb cue supplies and ~ under !be exp1ic:it lenns aDd cooditiOllS
cODlaiDed in die various CORR-COIIIIIlctioa oeaotiatecl poup pun:llasiDl qreemeolL Sucb pwthases sba11 include
product UDder MEDI~URGlCAL, PHARMACY, LABORATORY, DIETARY and CAPITAL EQUIPMENT'
ProdUClIines.
n. PROGRAM PARTICIPATION FEES
As coosideratioa Cor access to CORR oelocialed poup pmdlasiDs a6'~"""" the ParticipatiDa Member agrees to
pay 10 CORR a propam partidpllioil Cee . set COI1h in the ""-'-I sc'-ln"'.
IlL SUPPORT 01' PROGRAMS
The ParticipatiDl Member underslaDds. acbIowledgea aod spec:ifica11y apees 10 use ill very best efforts to
exclusively suppot1 all CORR-Coooectioa oelocialed poop purcbasinl qreemeoll offered 10 member facilities
whenever possible aDd practicable. The sole aUowable exceptioa beiDl in product areas where COHR-Coooectioa
does DO( curreotly possess a oesodated pvup pun:basiD1 apeemed..
I
IV.
VENDOR COMMITMENT LETTERS
By virtue oC sectioa m above, the PartieipatiDs Member, as a coodilioa oC membersbip, shaD apee 10 execule aD)'
approprialll .vendor commilllleDlletterslagreemeDlS" as may be required by cataiD individual veadon. supplielS or
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;. .:.: IDdeIi~.&p..jlIiu ~_A...i~1eaen or &JsiCCII.-tS. COHR'1s simply providiDl a service for!beinl!" I beOe .",,.':
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'. '. .,' ,"Tbil:PanicL~ .mbi~~~p.diit1poli_.,' .," rCOHR.'iOpaidoo..of~tbi;';piO .. -. .;".
." .....c./PUtice ~ .:ID m&r,cbaase,liom limo to time:..1bePuti~ ,. ""'. - . ,r <J.~
~:,.... ::.:.t'r~"\"""'" \~.., .._r. '~""";>;:';"'L--"-'od-" ~~'''''';;,.;;;-~~.' ..,,-__........IIO-;"''''*'' ~~~1;j.
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~";.; /;.~;..t~.! ....l'\~6~'di-1'.:c '- ~\;oi.l,=,.f '~'''<'.:::~~~''':~''--~'''f' .,*" ~.\t....,--<<-:..~~, '-"~'~"" 1i. '.~' '\ \ ~";\',.."
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~'~'" ... '. :{X~~. .' ,,!.:~:...:%.'t""~~ ,'" .:-~1.';t"'*-"':t,' ~~l"......tJ" ~~.~,,~1';< .:-.:,;;.0;.....,.;:. .,:;.,~:~:~~:~~~..:. ~.t-~- ~~~,;;,,""'~""'.':.. ~ ":'".~..:i- .
.....,~'!.._..., '. ....{".'~ .-;1..;:'_ -~~l~ . <~A.:\'-.f~.l.trJl -:..~~..\.:,s:.f;....,l<'.i1,....~~'~~--::"..,.j..,...~?.- .;.t.: ~e ....,..1...'.~.....JI:i:.{.\t.7;:-.r.,.y'..!,.".ot..t~t..".(..t! . .,:-i:t;;. .
"..\~ ~.~kt.~"~~l-"'?i,:~(~}_~' "':>...h.(';,!.~f~r.:,;:..<i~7.~::~~f,:;....;.J".::.:,"'.. '~i~_;,;~:~~. S...,i~.::.:~Ii~..~~~~i:.::-;.-~ ~-li
,.' ~~,.,~. ~":nIe~ietaito...y. .~. .: ~...~,. ".,. .." r ~ '~M~~iI',~. -....
COHR-C()o--'<I"";~paa.Ol aegotiJled:pOup purcbuiDllao-..cs; 10 !be eud of COHR'i - -
. ~. .'Ag[c:. ..:~_~!~,7...4.~~t:"~he(':2>-;~~.~~p.I_~~ :... . .....,
.... ;"t~~,'t~i;;~~~.1..,1~l~~~~~1.~fi.Biii;t~~~j~~~%~.~"i~;~~t:;.
. '.,-'~ vri.. :.eo,.~~~t~rN'~...~;..:~~~~~,.~;~. ~ ~'.'.' ... ~"~~ "-'r..-~~,,:.,:. ,,;. ;~,~:~:;.(~.j .,_.,k7~ ':~>~;m.'" . ::, :-,.;;:.;"."
. _ "COHR:wiIl,~. ni:ofc:baipia<l) complete set of Aarccmetll biDdCn eilber'iD miaoficbe,olr- .
. .;~.~i':t;,i..{\,'1i..:.,ve~. .P..O:W~' ON(1a aYiIbbIe.with ,'''It'..... ';f..;,.....tiid.b..c1....oIl. .. .. . . .~
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'. . C be .Cat.IOiii;;ro..i'~'..~~11ie'Iiii. ';;' OliiiTil~~f~.+J::-~':'~'.. ..
replacemear: Said fee CIII be It-".... upoa reqaest.." . '.. "c.' .....'''\~<\I,,!:'.c... '''''''',c.''''-"""""., .x.,' "
.;_ ,,' ~.,:- v.:'1r\~::~~.;.t;"i" ~ . .' ..-..... " "'$';' . ' '-. . '. - . .--><!s:,1.... - '. ~":..\.,.~. '."--. -~... -",
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vm-- . CANCELLAnON.AND.TERMlNAnON'~'l.,..'"",,.!!h~~~\;?',n ..' . "'.c-"1""',,;".' ...,.o.?:\'..... ."",,~.;,;.~{',~~,
.' . .~;~~';..~,;-",~.;,.: .;'-. ..' .,.-".._ ;" :.' ". :t;;:i..;;;.,".. .. _..,.....:~;~~':.,.:-. ~':'...,~ . .
COHR:c....-::tlOa\___..A.lbeulgbt.to ClIDIld ,1Dll. ___lReta.tbe,ri~Ol'a'. PutlcipatIDI. MeaibelibDcter. this ..,. ~ .
, '. . .. ....l . - - .
AgreemeDl as foOowr. .... .'f. .. .. " . .,'~.rl<.::- .
A) . rm_otPIy upoa aatIce ....._ 10 IeClioa X below; or
9) W"1lbID tbirty (30) ~ wrillalllOlice to !be J'a1ftripori.. MembeI; or
C) For v101adOlll of ~llD XXII c:on6Mftri.lily provIsiom; or
,'~ ~ ~ ~ .
.,
D) For faIhn to ~ 10 sectioo XXV provlsiom.
lbe PaniclpatiDl Member may caned aDd cenniDalD its rigbls UDder Ibis Agreemeol DpllD thirty (30) days Wrillen
DOnee to COHR~OG. In !be _ !be PutlclpatiDl Member elect3 to 1erminale a provided for above, DO
monies ptevlousf)' pIiclto COHR will be refuoded If !be A~lllleml bas Ibree (3) moodls or less mnaiDlDg aDd
aD curmllIy out-",U"llDvoica due COHR-CoooectIllD wiI1lmmedialely became due IDll payable..
IX. INDEMNIF1CAnON
9y ill! continued participation in !be COHR-CouoectlOtl programs, !be Participating Member bereby expressly a~es
10 indemnify aDd bold-bannless COHR-Connectlon agaiml any and aD claims. judgmeDlS, coslS. expenses or other
losses arising OUI of any COOOncl relatinlto !be use of or UDder lbe authority of COHR-CoooectIon oegolialed group
purchasing agreementS. wbere cooduc:t of !be PaniclpatiDl Member faI1s 10 expressly confonn to IDll comply with
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outlined COHR-CoooecUon roles. policies and/or din:ctives.
x. "OWN USE" POUCY
The Participating Member ellpressly and UllCquivocal1y uode.mnds and agrees thal eacb and every purcbase made
througb anY COHR-COllllectiOD negotialed group purcbasiDg agreemeDlS for bealth care supplies and equipmeol are
for thal Participating Members' ultimate cODSumplion or "owu use." "Owo use" being de60ed by any of tbe
foDowing:
A) Those relevant sections of the Ptescriplion DNg Muketing Act of 1987 and any ameodmeDl
therelo. and/or
B) Those relevant sections Robinsoo-Patman Act of 1932 and any amendmeots thereto. aodIor
C) The United Stales Supreme Court decision in Abbott Laboratories et al. v. Portland Relail DruRltiSl
Association. lIlc:.. Elc. (1976) 42S US l.
TlUS AGREEMENT SHOULD NOT BE ENTERED INTO IF THE PARTICIPATING MEMBER IS NOT
ABSOLUTELY CLEAR AS TO WHAT IS MEANT BY "OWN USE" AS IT RELATES TO PRODUCT
PURCHASED PURSUANT TO TIllS AGREEMENT.
Additionally. !be Participating Member UDdeIS12Dds. acknowledges and coDSeDlS 10 baYing its membelSbip
immediately and UDCODditiooa1ly termioaled following COHR-Coooection's discovery thallbe Participating Member
bas violated or acted in ID iDc:oosi,-- maDDer 10 !!!1 provision of this subseaioa.
XL ASSIGNMENT AND DELEGATION
This apeer- eat and any addeoda to it sball DOt be lIIDSCenble, assipallle or delegable without Ibe ellpJeSS wrineo
cODseDt of COHR-CODDeClioa. MY attempted assipllDelll of this &peemelll or delegation of any duties UDder il
without expIeSlI prior wrilleD IIllborizalion of COHR-CoooectiOll is void.
xn. DISPun; RESQLunON
My dispute arisiJII bd w<<:D the Parlicipatinl Member and COHR-CooDectiOll UDder this agreemeat wiD be senJed
in the foUowing IIWIIIeI:
A) Any dispute reprdiDl a claim for damaaes within Ibe jorisdictiooa1 limits of small claims divisioo
of !be MUDic:iplIl Court. LoI Mleles JucIldal District, wiD be JeSOlved by thal court.
B) Any dispute benreea !be Participatinl Member and COHR-CoooectioD arising out of this
A,.-1Il must be submitted to biDdinl azbitntiOD if Ibe amOUDl in dispute exceeds the
jurisdiaiooal1imits of !be small claims court. but does DOt exceed a loW of 6fty thousand doUm
(5'0.000) iD asplate c1aim(s). AAy and all disputes arbitraled and decided UDder this sectiOll
shaD be CODSidered FINAL AND BINDING. AAy sucb azbitration will be WQducted iD Los
Mgelel, CaliCOIDia iD suitt accordaDce with !be Commercial Rules of The American Milralioo
Association. 1be tusiag part)' wiD bear the attomey's fees aod costs of the prevailiDg party.
C) Any claim or claims by ei!ber part)' Igainsllbe ocher thal sbouId exceed an aggregate lOIal of 6 fly
tbousaod doUan (5'0,000), wiD DOt be eligible for arllitratiOll as DOted above. ID sucb ID eveol.
!be parties agree to relaiD their respective legal rigbls and sectioa xm below wiD become bindinc
and eofon:eab1e.
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TbII';i;''"';~_~- ,m.1 "---d71a~_Cir_~;' ~'IIdaOlwblcla""I(' ,,;. 10.
oriailllll; b..:.:.......oIwb1c1a....cor-ri.... but_...... - ...~. .-. .~....,:
XIX. SEVDABILI'I'Y
SboaIdaCGlll-of Ill"... II).... .. j~.......,of"''''lN';' ...:lWPoIIiD.......u ~.....tD..~orlO
be 0Ih..__' . 1 ,. ..... ___.. be" '1\1..... ApI -...... -..... _lM-..... be
Ii-Ildlll", ~ ... eIIIcL: .
xx. w ARa.UI'I'IBS
1be PanI.I. -....... LIf.... ~... ..uc:....... .... COHll-C M ~a dlnlaF
pili L "'I.' II....... .......lIIllilaat..-.,...W--...,...' lp\,
veador. 111--' or ......... wIda wIIIclI COHll.... ~sa" . (...,. r-' '"'I....'
COHR mabI.lMtl_.. A...t.... ...__ u. eiIbIr........ · or Jmpu_.a .. ..,.....wba...>-
widlout II-~ eo.... ta tit! ... 81. L........." or IIIaeIItbr ......-. witb IIIpIClIO ...".
servic:es ll.u.1ded ........10 dill AlIH'm - ....dd1ol,.,..lIy. CORR .........IID IIaIIIIlly .~
injuJy. l"ujleftJ ....... or loll pnlilI CIIIIIlI by or JellIed 10 ... Ibove ~ ""II ,.odacII or .,
~l & ..lLpoup
_Iler IIId IDY
Acc:anIinPJ.
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pmdacts or
"or persoaal
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XXI. PARTICIPATING MEMBER'S OBUGATION FOR PAYMENT
Participating Member sball pay !he maou(actwer, distributor or wholesaler dUe<:tly (or any and all equipmenl,
supplies or other purc~ pwcha.sed by !he Participating Member uDder !he authority of and pursuad 10 this
Agn:emeot.
xxn. WARRANTY OF CONFIDENTIALITY
Participating Member recogDizes. uoderslaDds aod specifically acknowledges tbaI!he mat.erial beiDa pIOYided 10 il
is (or tbaI member's use oaJy. Participatina member absolulely agn:es DOt to divulp. fuJ1Ii.sb or make accessible
to anyone. o!her than oecessary employees of !he ParticipatiDg Member. any knowledge or iotormalioa with respect
to pricina. products, coolrac:t telDlS or other setvices offeled by COHR-CoDDeClioa propama wbicb is DOt otherwise
generally moW1l or available to the iDdusUy. The iotonnalioa provided punulllll to this AgRCmeDl is
CONFIDENllAL. Failwe to exercise reasonable p~utiODlto protect !he coa6dellliality of this iotormalioa would
be grounds for tenninalioa of this Agreemem aod could resull iD substantial civil peoalties 10 lbe Participating
Member.
XXIII MEMBERSHIP INl11ATION
WIleD accepled. membelSbip 10 1be COHR propama of oeaotiated group pun:basiDa agreemeolS will DOt commeoc:e
earlier thao thirty (30) caleodar days from receipt iD COHR', offices of 1be propedy executed participalioa agreemeDl
aod completed'IDformatioa Sheet.
XXIV. UPDATING INFORMATION SHEET
The Participating Member Uudb.uads. acbIowledges aod agn:es Ihal it is the fadIiIy', duty aDd obIiplioa to update
the IDfoll1latioa Sbeet oa an aDIIIIIl bam or sooaer if Ibete is I mllerial cbaDp ia !be Participatina Member',
busi.oea or operatioaL "MaIeriIl 0-,." sball be iotell'.~ted III iDcIude, bat shall DOl be Umited Ill. sac:h cbanges
IS owoenbip. ellpiralioa or revocadoa of ~ aDd lbe lite. FaiJun 10 update 1be iotormadoa fonD as provided
for above could teSUll ia _1-'- punuaat III secDoa vm.
XXV. ADMINISTRATIVE FEES
The Participating Member is aware aod 1Dleataoda tbaI Admioistntiw Fees may be coUected by COHR-CoooecIiOD
from veadon. supplias uJlor wbol...,-, based oa sales III the PartidpatiDl Membem. CoUectioa of lIlY sucb fees
is 10 assist the fuadiaa of the COHR-Coaoectioa ptoIrIlIII sod shall be ill full compliaoc:e with CIIIreal applicable
federal law mJlor reJUlatiOlll.
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XXVI. ENTIRE AGREEMENT
This Agree~ ...-tiI..u lbe eodIe aocIeISIaodiDI aod agRC_1Il betweea lbe parties witb respect 10 !he subject
malt.er described beIeiD Uld supeaedes illY prior uodelSlaDdial or,tat.emelll of cooditioas or iDleIIL In affixing !heir
signatwe thereto, DO party is relyi.aa oa aoytbial DOt sel fOllb beteiD abo1e.
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IN w..I"IIlSS,......... dIiI~ II eo. ~ ill ~ by .~,'nri2ied...... of lbepMill:'
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FACIUlT"
COIlJl.CONNECTION
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APPROVED AS TO FORM
AND LEGAL CONTENT.
("-'1 .
James F. Penman,
City Attorney
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ADDENDUM
PURCHASE CONNECTION
INFORMATION SHEET
The roUowiol iDConnatioa must be provided 10 ellSUIe
thai you JeCeive all of the correct priciDl aad iofonnatioa.
AgreemeDl tanDOt be pnxessed wilbout this completed ronn.
(please Iype or print)
Facility Name
Facility Address
City
SIaIe
Zip
TeJepbooe .
Primary toatm persoa
MedicalJSurgic:ll
FAX'
Pbarmacy
Capital
DietaIJ
l.abonIoIy
RadlololY
.AAminlctralioa
Modem .
BAUD RaIII
DEA'
Rx Wbolesaler/OlvUioa
Health tndusUy Number (HIN) (wIleD avlilable)
Prosnm Materials to be provided oa: paper
mitlOlldle _
eledroaic:ally