Carolinas HealthCare System

Diversity Development Group
4828 Airport Center Parkway
P.O. Box 32861
Charlotte, NC 28232

Phone: 704-512-7772
Fax: 704-512-7904
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* Indicates required information
GENERAL CONTACT INFORMATION 
Company Name * 
Principal's Name * 
Address * 
Address (Continued) 
City * 
State * 
Zip * 
Telephone Number * 
Fax Number * 
Principal's Email * 
Contact's Name * 
Contact's Title 
Internet Address 
Year Established 
Average Number of Employees 
Tax ID Number 
Dun & Bradstreet Number 
GROSS ANNUAL SALES FOR LAST THREE YEARS: 
Year/Amount * 
Year/Amount * 
Year/Amount * 
Legal Structure 
Percentage of Minority Ownership (%) 
Diversity Category 
U.S. Citizen * 
Veteran * 
Disabled Veteran * 
PRODUCTS(s)/SERVICES(s) 
Product(s)/Service(s) Description * 
Type of Business/Commodity/Service 

If Other, please specify:

Standard Industrial Classification (SIC) Code * 
North American Industry Classification System (NAICS) Codes 
Geographic Service Area * 

If Other, please specify:

I.S. Capabilities? (Electronic Data Intercharge) * 
REFERNCES (MAJOR CUSTOMERS; LIMIT3) 
1. Company Name * 
1. Contact * 
1. Phone * 
1. Product(s)Services(s)Sold * 
2. Company Name * 
2. Contact * 
2. Phone * 
2. Product(s)Services(s)Sold * 
3. Company Name * 
3. Contact * 
3. Phone * 
3. Product(s)Services(s)Sold * 
CERTIFICATION 
Note: You must provide a copy of your certification (as an M/WBE). 
M/WBE Certified? * 
If yes, please list your Regional Council. 
Regional Councils Certification Agency 
Regional Council Expiration Date (mm/dd/yyyy)  (mm/dd/yyyy)
State Certified? * 
If yes, please specify. 
State Certification Expiration Date (mm/dd/yyyy)  (mm/dd/yyyy)
Other Certifications? * 
If yes, please specify. 
Other Certification Expiration Date (mm/dd/yyyy)  (mm/dd/yyyy)
 
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