PLEASE COMPLETE THE FOLLOWING QUESTIONS:	YES		NO
1.	Does your firm accept purchase orders via FAX?
2.	Does your firm accept orders electronically?
3.	Does your firm invoice electronically?
4.	Does your firm accept remittance electronically.
5.	Is there a charge for delivery?
	Is it a set fee..
	or actual charges?
6.	How many days is a standard delivery?	____________days
7.	How many days is a rush delivery?	____________days
8	Do you have any relatives employed at any Sarasota Memorial Health Care System?
	Name:_____________________________________________
	Dept:  ____________________________________________
	Relationship:  ______________________________________
9.	Is your company at least 51% owned, operated and managed by a caucasian female.
10.	Is your company at least 51% owned, operated and managed by one of the ethnic groups below.
	If so, which ethnic group?
	Qualifying Ethnic Groups:
	African American (any black individual of the racial groups of Africa)
	Asian American (any whose origins are from japan, China, the Phillipines, Vietnam, Koria, Somoa, Guam, the U.S. Trust I Territories of the Pacific, Northern Marianas, Laos, Cambodia, and Taiwan)
	Asian-Indian American (Any whose origins are from Japan, China, the Phillipines, Vietnam, Korea, Somoa, Guam, the U.S. Trust I Territories of the Pacific, Norther Marianas, Laos, Cambodia and Taiwan)
	Hispanic American (Any whose origins are from Spanish or Portuguese culture including Mexico, South America, Central America of the Caribbean Islands)
	Native American (American Indians)
	Printed Name:___________________________________________
	Signature:__________________________________Date:__________
	Title:___________________________________________________