Supplier Diversity

* Fields or sections marked with an asterisk (*) are required.
*Company Name:
*Telephone:
Fax:
*Address 1:
Address 2:
*City:
*State:	--Select State-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
*Zip:
*Contact Person:
*Title:	Miss Ms. Mrs. Mr. Dr.
*Email Address:

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Please furnish the following information about your firm:

*Federal Tax ID:
*Primary Type of Business:	--Select Type-- Broker Dealer Retailer Distributor Service Manufacturer Manufacturer's Agent Wholesaler Other (specify below)
Other (please specify):
*Legal Structure:	--Select Structure-- Corporation Partnership Sole Proprietorship Joint Venture Franchise Other (specify below)
Other (please specify):
*Geographic Coverage:	--Select Coverage-- Local/Regional            National
*Number of Years in Business:
*Number of Employees:

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*Please indicate whether your company is a woman- or minority-owned business:

	Minority-Owned Business A business at least 51% of which is owned (or in the case of publicly owned businesses, at least 51% of the stock of which is owned) by one or more minority individuals and whose management and daily operations are controlled by such individuals.
	African American Hispanic American Asian American Pacific Islander Native American(American Indian, Eskimo, Aleut)

Non-Minority Women-Owned Business A business that is at least 51% owned, controlled and managed by non-minority women or woman.

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*Please indicate your certification status:

	Certified by an authorized agency.
	Agency:

I herewith self-certify my status as a minority- or women-owned company.

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*Please supply the following reference information:

Prior Business with Food Lion
Have you ever done business with Food Lion?Yes No
	If yes, please indicate the year and your Food Lion Contact.
	Year:    Contact:

Additional Comments

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*Please tell us about yourself:

I am the Contact person listed above. If you are not the Contact person listed above, please complete the following:
Your Name:	Miss Ms. Mrs. Mr. Dr.
Email Address:
Telephone:

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*Please tell us how you found out about this program:

Contacted Food Lion myself

--or--

Trade Show/Conference:
Magazine:
Newspaper:
Web Site:
Company:
Other: