UTHealth Discount Program

• Name of Provider
• Federal ID Number
• Years in Business
• Name of Authorized Agent
• Title of Authorized Agent
• Telephone Phone
• Email Address

• 一个ddress
• City
• State
• 邮政编码

• 一个ddress
• City
• State
• 邮政编码

• Discounted Product or Service Offered (in 75 words or less)
• 大量的折扣
• If other, please explain
• Special Instructions or Limitations (in 75 words or less)
• 折扣网站（如果适用）
• Discount Code (if applicable)
• Is the business related in any way to any UT System or UTHealth officers or employees?
  • Yes
  • No

By submitting this form, the provider acknowledges and agrees with the provisions of the UTHealth Vendor Agreement and certifies that the information provided in this form is true and correct.

Enter the full name of provider (or authorized agent) below.

• 一个uthorized Agent
• 日期

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