Non Centrally Funded Customer (NCFC) Account Application Form

NHS Supply Chain provides customer-focused healthcare products and supply chain services to the UK’s National Health Service (NHS), enabling trusts, hospitals and other healthcare organisations to focus on patient care.

Under the terms of our charter, NHS Supply Chain is only able to provide this service to front line patient care providers. It would therefore be most helpful if all the fields indicated on the application form could be completed as this will enable us to process your application in a timely manner.

As an added benefit for registered Charities and NHS charitable funds we can offer VAT zero rating on medical/scientific items, so please ensure that you complete our 6 month certificate and return with your application form.

If you have any further queries then please do not hesitate to contact us.

National Admin Team

csadmin@supplychain.nhs.uk

0300 013 6208 extension 2182

Step 1 of 3

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What account type do you require?(Required)

New Account

Additional Requisition / Order Point

Existing account number/requisition point(Required)

Please tick which of the following applies to your organisation(Required)

NHS – Organisation with over 50% funding by the NHS (such as most GPs)

Private Less than 50% NHS Business Activity – Provider has less than 50% of NHS Business Activity

Not for Profit – Provider of healthcare services on a not for profit basis e.g. voluntary, hospice, charity, social enterprise

Wider Public Sector – Public sector health related customer, for example Local authority, MOD, prison, school (home countries)

Private – Profit making organisations using heath care services to achieve core purpose profit for example Spire, Bupa, BMI, non-NHS Dentist

Purchases with charitable funds – Eligible organisations to benefit from VAT zero rating on medical/scientific items

Private Greater than 50% NHS Business Activity – Provider has greater than 50% of NHS Business Activity

NHS Service Provider – Organisations contracted to provide healthcare services and guarantee to only use products on those contracts

Trust Capital purchases – Enabling trusts to administer transactional capital purchases

Managed Service Provider – a vendor-neutral managed service to the NHS

All sections must be completed, with as much infomation as possible.

Section 1

Nature of Business(Required)

Brief Description of Services to be Provided(Required)

Organisation Name(Required)

Invoice Address

Building Name / Number(Required)

Address Line 1(Required)

Address Line 2(Required)

City(Required)

County(Required)

Postcode(Required)

Contact Name(Required)

Job Title(Required)

Telephone Number(Required)

Website(Required)

Email Address(Required)

Enter Email Confirm Email

Company Registration Number(Required)

VAT Number(Required)

Are you a registered charity?(Required)

Yes

Charity number(Required)

We will require you to complete a Customs and Excise Compliance / Zero Rated Supplier Declaration. Please download the Declaration using this link and follow the instructions contained therein.

Is Parent Address different to Above

Parent Company Address

Building Name / Number(Required)

Address Line 1(Required)

Address Line 2(Required)

City(Required)

County(Required)

Postcode(Required)

Telephone Number(Required)

Email(Required)

Enter Email Confirm Email

Delivery Location(s)

NHS Supply Chain delivers to a wide variety of healthcare locations, from hospitals to small GP clinics and dental surgeries. It may therefore be necessary to carry out a road and access suitability assessment and to confirm where you would like your goods delivering. If this is required for your location, we will carry out the survey when making the first delivery.

Is the Delivery Address different to the Invoice Address

Department Name (Requisition Point)(Required)

Building Name / Number(Required)

Address Line 1(Required)

Address Line 2(Required)

City(Required)

County(Required)

Postcode(Required)

Telephone Number(Required)

Email(Required)

Enter Email Confirm Email

For more than one delivery location, download this file complete the form, save it then use the upload button to add your file to this form

Multiple Delivery Locations Spreadsheet Upload

Max. file size: 256 MB.

Section 2

Anticipated frequency of order?

Weekly

Monthly

Other

What types of products might you purchase from us? (please tick all that apply)

Cleaning, hygiene and infection control products

Clinical products

Continence products

Dental and optical equipment

Drapes and gowns

Dressings

Food and catering products

Furniture and fittings

Hearing aids

Laboratory instruments and equipment

Office equipment and stationery

Operating theatre products

Protective clothing for example gloves / masks / aprons

Rehabilitation for example crutches / walking frames

Women and child / sexual health promotion

Expected annual spend?(Required)

NHS Supply Chain only emails invoices, please submit an email address for our records

Email address for invoices(Required)

Enter Email Confirm Email

Section 3

What percentage of your sales turnover is NHS Business?

Please attach evidence to support this statement(Required)

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 20 MB.

Section 4

Do you wish to purchase now or at any time in the future products classed as “Licensed Medical Products” (LMPs)(Required)

Please attach evidence to support this statement(Required)

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 20 MB.

If Yes, you must complete all the sections ‘What type of products will you be ordering from us’. Failure to provide sufficient, verifiable evidence of your suitability to order LMPs will result in you being unable to place demand for this range, even though you may be able to view them in our catalogue.

Acceptable evidence is one of the following:

A copy of your MHRA Distributor or Manufacturers Licence (if applicable).
A headed letter containing the following – GMC / GDC / GPhC registration number, forename(s) and surname.

As part of MHRA requirements placed on NHS Supply Chain as a distributor of Licensed Medical Products we are required to undertake customer validation checks and as such we reserve the right to restrict supply of Licensed Medical Products to validated customers.

Please note evidence provided will be routinely subject to re validation, subsequent failure will see the range removed from your access.

Section 5

What type of services do you provide to the NHS?(Required)

Which NHS customer are you providing services to?(Required)

What type of contract agreement is in place and for what duration?(Required)

Are the products being used within your own organisation at the delivery location?(Required)

If products are to be sold onwards to the NHS or another organisation, please provide details(Required)

Are there any other considerations to be considered for example any known clinical impacts directly linked to the ability to transact with NHS Supply Chain?(Required)

Section 6

Terms of payment are strictly 30 days from date of invoice.
Orders below £120 will incur a carriage charge of £7.50 (inclusive of VAT).
The account must be used monthly or we reserve the right to terminate the account.
Depending on volume, we may use Roll cages to fulfil your delivery. Roll cages are a critical resource for the NHS and shortages significantly impact our ability to provide a satisfactory service to our customers. It is therefore the delivery location’s responsibility to adhere to the below;
- All empty roll cages are to be folded down and stacked together ready for collection.
- Cages are not to be used for storage, or the transport of laundry under any circumstances.
- All roll cages are to be returned on a 1:1 basis.
Repeated failure to abide by these requirements may lead to cages being withdrawn and replaced with pallets on future deliveries.
This agreement does not permit you to use these products for any other customer other than stated above. Evidence of such practices will result in the termination of your account.
By typing my name / signing below, I certify the above information to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing my application.

Print Name(Required)

Position(Required)

Signed by(Required)

Date

MM slash DD slash YYYY

Consent

Please note that your contact details will be kept securely in our database and will not be disclosed to a third party. If you are happy for us to contact you from time to time with further information about products and services which may be of interest to you, please tick this box.

Comments

This field is for validation purposes and should be left unchanged.

Non Centrally Funded Customer (NCFC) Account Application Form

National Admin Team

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