Supplier Name Letter of Participation - Contract #

Note: This Letter of Participation (LOP) may be completed only by representatives of E&I member institutions. To determine whether your institution is a member, visit our Member Locator. To join E&I, complete a Membership Application

E&I Member acknowledges that it may elect to participate in only one (1) SUPPLIER agreement at any given time, and hereby agrees to purchase SUPPLIER products and services in accordance with E&I / SUPPLIER Master Agreement CONTRACT#. E&I Member agrees that this Letter of Participation Form for the above referenced Agreement shall supersede all previous declarations for the purchase of product and services from SUPPLIER unless otherwise specified. E&I Member further understands that enrollment in this Program will remain in effect during the Agreement term, including any extensions.

Upon receipt of this Letter of Participation Form, SUPPLIER will enroll E&I Member in the program. Processing this form will take 4 to 7 business days (during the initial contract launch and during periods of increased Member activity some additional processing time may be necessary). An e-mail notification will be sent by SUPPLIER informing E&I Member that the new or existing account(s) is now linked to this Agreement.

E&I shall follow-up with the E&I Member to ensure successful enrollment as well as to provide additional contact information for both E&I and Business Partner.

If you have any questions about this form, please contact your E&I Member Representative or BDM Name by email at BDM email.

By completing the form below, your Institution is requesting to be enrolled in the program.

We are a current customer. We are requesting to have all existing accounts (specified below) to be linked to the E&I Master Agreement.We are a new customer. We are requesting a new account to be set up and enrolled under the E&I Master Agreement.

Institution Information

Institution Name	Title
Business Unit	Primary Role
First Name	Last Name
Phone	Email Address
Additional Contacts Please enter one contact per line. Please include the contact name, phone number, email address.	Account Number(s) Please enter one account per line. Please be sure to include account numbers if known.
Designate Different Primary Contact NoYes	Primary Contact Please provide Name, Title, Email, and Phone Number

Billing Information

Billing Contact of Department Name	Address 1
Address 2	City
State	ZIP
Phone # associated with your account

Dealer Information

I know my dealer NoYes	Authorized/Servicing Dealer
Dealer Contact Name	Dealer Phone #