Life Event Management Services : LifeCare

LifeCare Supplier Diversity Program

Vendors interested in being included in LifeCare's Prospective Supplier Database should fill out and submit the form below.

PLEASE NOTE THAT YOU WILL NOT BE CONTACTED BY LIFECARE UNLESS AND UNTIL A PURCHASING NEED MATCHES WHAT WE DETERMINE ARE YOUR COMPANY'S QUALIFICATIONS, AS DETERMINED AT LIFECARE'S SOLE DISCRETION. AT THAT TIME YOU WILL BE REQUIRED TO PROVIDE PROOF OF STATUS AS EITHER A MINORITY, WOMEN, PHYSICALLY CHALLENGED OR SMALL BUSINESS.

Learn More about LifeCare Supplier Diversity Program

* = required information

Company Name and Contact Information


Company Name *
Address *
City *
State *
Zip *
Telephone Number *
Fax *
Contact Name *
E-mail Address *
Contact Title *
Website

Business Ownership Classification


Company Status *
Gender *	Male-owned business Female-owned business
Ethnicity *
Disabled/Veteran *
SIC Code
NAICS Code *
DUNS Code

Business Information


Annual Sales ($) *
For the Year *
Projected Sales ($) *
Service Area *	International National Regional Local
Incorporated *	Publicly Held Privately Held
Total Employees *
Minority Employees *
Principle Products or Services. *

Certification Information

Has your company been certified by any regional purchasing council?
If so please list.

Council:

Number:

Date:

Has your company been certified by the Small Business Administration?
If so please list.

SBA Certification Number:

Date:

Other agencies that have certified your company.

Agency:

Number:

Date:

Major Customers That You Do Regular Business With

Customer:	Contact:	Phone:

Customer:	Contact:	Phone:

Customer:	Contact:	Phone:

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