Healthcare - Purchase Agreement Request for the Ecolab OR Program and/or Surgical Room Turnover

Account Executive Information

First Name *

Last Name *

Phone Number *

Email Address *

Customer Information

Customer Account Name (Full Legal Name) *

Customer Account Number *

Phone Number *

Street Address *

City *

State *

Zip Code *

Number of Active Operating Rooms *

(If Applicable) Customer's Distributor

GPO Affiliation

GPO Tier Level

Save & Return

Save your progress and complete this form later. (Optional)

Agreement Information

Agreement Type * 🛈

Ecolab OR Program

Ecolab OR Program Renewal

SRT Kit Only

SRT Kit Only Renewal

Terms *

24 Months (2 Years)

36 Months (3 Years)

Terms for Ecolab OR Program *

36 Months (3 Years) - Terms less than 36 months require Marketing approval

If Ecolab OR Program (Microfiber Choices From Drop-Down Menu) * 🛈

If Ecolab OR Program (Guarantee Options) * 🛈

Improve the HTO cleaning score from baseline, to percentage listed *

Improve the Turnover Time upon Turnover Baseline, by percentage listed below *

If SRT Kits (Guarantee Options) * 🛈

Product Information (Must Be Completed Before Submitting)

Provide the kit/product number, case quantity, and case price below:

	Product Number	Case Quantity	Case Price
1	Product Number	Case Quantity	Case Price
2	Product Number	Case Quantity	Case Price
3	Product Number	Case Quantity	Case Price
4	Product Number	Case Quantity	Case Price
5	Product Number	Case Quantity	Case Price
6	Product Number	Case Quantity	Case Price

Required For Ecolab OR Program Agreements
Please add MF92053N (50 per case) and 92000N (96 per case) along with case pricing* for each)
*This pricing can be found on the HC Reports Portal under Customer Pricing_PLM *

	Case Quantity	Case Price
MF92053N	Case Quantity	Case Price
92000N	Case Quantity	Case Price

Devices

iOS Device Option

iPod (Preferred Option)

iPad

If more than one iOS device is required, please provide explanation and total quantity. Additional licenses for use on the facility's own devices can be considered. Contact marketing if interested.

Hardware

The customer becomes eligible for hardware items after the Agreement has been duly executed by both parties. The Hardware Order Form is located on the website or by clicking this link OR Surgical Room Turnover Hardware Request Form

Comments

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Purchase Agreement Processing Time: 5-7 Business Days