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K12 Market Basket Request Form

To get started with the K12 Market Basket, please fill out the form below.

(*) Required fields.

Contact Info
First Name

Last Name

Title

Phone

Fax

Account Information
Agency Name (Roster Participant)

Federal Tax/Employee Identification No.(TIN/EIN)

Primary Street Address

City

State

Phone

Fax

Agency Type
Agency/Facility Type

Food Purchasing
Estimated Annual Foodservice Purchases: $

Current Foodservice Distributor(s)

Average Days Sales Outstanding

Scheduled Food Deliveries Per Week

Average Food Drop Size: $

Terms and Conditions

I agree to the Market Basket Terms of Use required in order for a pricing analysis to be performed and represent and warrant that I am duly authorized to bind the Potential Roster Participant to the Terms.

Potential Roster Participant hereby requests that Provider Select, LLC (“Premier”) provide to Potential Roster Participant a market basket pricing analysis (the “Pricing Analysis”) in connection with Premier’s food service offering that is available to Potential Roster Participant through Premier’s relationship with OMNIA Partners (subsidiary U.S. Communities). Potential Roster Participant acknowledges that the Pricing Analysis contains confidential and proprietary information of Premier and its affiliates and Potential Roster Participant shall (i) maintain the confidentiality of the Pricing Analysis, (ii) refrain from disclosing the Pricing Analysis to any third party outside of its organization, and (iii) use the Pricing Analysis for the sole purpose of evaluating the opportunity to participate in the Premier food service program and for no other purpose.

In the event that Potential Roster Participant is subject to applicable open records laws which may require Potential Roster Participant to release the contents of the Pricing Analysis, Potential Roster Participant agrees to promptly notify Premier of any request under such laws for the release of such information. Further, Potential Roster Participant shall cooperate in good faith with Premier and its affiliates and use its best efforts to assist Premier and its affiliates in preventing the release of such information to the extent consistent with applicable law.