Step 1 of 5: Group Purchasing Participation Agreement

Thank you for your interest in joining CCPA Purchasing Partners (CCPAPP) as a Member! Before you begin, please review our CCPAPP Group Purchasing Participation Agreement.

View Agreement

If you are agreeable to the terms and conditions of this agreement, please proceed with the Membership online application below.

In witness whereof, the parties have caused this Agreement to be executed by their respective authorized representatives, effective as of the date in which the information below is submitted electronically to CCPA Purchasing Partners. The parties expressly agree to enter into this Membership Group Purchasing Participation Agreement in electronic format, to be bound by the terms thereof as expressed electronically, and to the use of an electronic signature process as the parties' intent to be bound by such terms.

First & Last Name of Provider *

Practice Name *

First & Last Name of Authorizing Signatory *

Title of Authorizing Signatory*

Tax Identification Number *

Primary Practice Contact Information

Mailing Address *

Suite

City *

State *

Zip *

Contact Information

Phone *

Fax

Email *

How did you learn about CCPA Purchasing Partners?

Yes, I agree

To help ensure that your practice is accurately linked to our discounts, CCPAPP may provide your practice name, address, and/or other information listed on this form to any or all of our business partners. Please check this box to acknowledge that you are aware that your information may be shared. Please note: CCPAPP cannot process your application unless this box has been checked.

Step 1 of 5: Group Purchasing Participation Agreement

Member Application

Primary Practice Contact Information

Contact Information

How did you learn about CCPA Purchasing Partners?