Supplier Diversity Program

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.

    * indicates a required field

    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:
    InternationalNationalRegionalLocal

    Incorporated:
    Publicly HeldPrivately 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: *