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 *
	AK AL AP AR AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY		State *
			Zip *
			Telephone Number *
			Fax *
			Contact Name *
			E-mail Address *
			Contact Title *
			Website *

Business Ownership Classification

	Foreign Owned Exempt Non-Profit Business Minority Institution (College/University) Historically Black College/University Large Business Small Business None of the Above		Company Status *
			Gender * Male-owned business Female-owned business
	Non-Minority Black American Hispanic American Asian Pacific American Subcontinent Asian American Native American None of the Above		Ethnicity *
	Disabled American Disabled American Veteran None of the Above		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

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