CSA Request Form

Today's Date * +

This is for EXISTING CUSTOMER who would like savings on GPO. This form will trigger our back office to create a CSA for a prospective customer to help you close the deal. Please collect as much vendor invoice data as you can prior to submitting this form so that everything can be loaded at one time. It is better to show maximum savings on a CSA from 4+ vendors, rather than partial savings CSA, so we'd rather wait to submit a stronger proposal, as opposed to sending them 1-2 savings quotes at a time while we're waiting for others.

Master Agent

Referring Agent's Name

Prospect's Company Name

Prospect's Contact Person

Prospect's Email Address

Prospect's Phone Number

Data you are uploading for the CSA

Enter verified vendor data here if you don't
have bill copies

Other Telecom Provider

DRAG AND DROP ALL YOUR BILLS HERE!
You Want Savings, We Want Your Bills!
The More Bills, The More Savings.

Comcast or Xfinity	DIRECTV	Spectrum
Cox	CenturyLink	AT@T
Dish TV	T-Mobile	Allstream
Telecom (COAX)	Telecom (FIBER)	Cellular for Phone
Utilities (Gas)	Utilities (Electric)	Worker's Compensation Insurance
Health Insurance	Property Insurance	Car Insurance
Credit Card Processing	Office Supplies	Durable Medical Equipment
Waste Management (Standard Waste)	Waste Management (Medical Waste)	Paper Shredding
Food	Beer - Alcohol - Wine	Produce
Alarm System	FedEx	UPS
DHL	Medline	McKesson
Dishwasher-Chemicals-Linens	Eco Lab	Farmer Brothers
Pepsi	Coke	Car Rentals
Air Travel	Home Depot	Uniforms