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.

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Company Name: *

Address: *

City:

State: *

Zip: *

Telephone: *

Fax:

Contact Name: *

Email Address: *

Contact Title: *

Website: *

Business Ownership Classification

Company Status: *

Gender: *

Ethnicity: *

Disabled/Veteran: *

SIC Code: *

NAICS Code: *

DUNS Code: *

Business Information

Annual Sales ($): *

YTD Sales ($): *

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: *

Comments: *

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