UPMC Perks Vendor Application and Agreement Form

Company Name: *
Main Business Address: *

Street Address 2:
City: *
State: *
Zip Code: *
Main Business Phone: *
Main Business Fax:

Business Location(s):

Company Website:
Primary Contact Name: *
Contact Phone: *
Contact Email Address:

Discount Details: *

Length of Time: *

Annual

Specific Time

How Discount is Obtained: *

Limitations, If Any:

Terms and Conditions

Submission of this completed form to UPMC signifies the vendor’s acceptance of the terms and conditions contained in the introductory letter that described the UPMC Perks program.

UPMC does not support, endorse, guarantee, solicit, nor does it have any interest in any organization that offers a discount to UPMC faculty and staff through the UPMC Perks program.

The employee, as an individual, assumes any and all risk in doing business with the vendor.

I agree to the terms and conditions stated in this agreement.