Vendor Application - FacilityCare

Trade Name *

Legal Entity Name *

Business Type *

Years in Business *

Federal EIN *

Annual Revenue *

Website

Street Address *

City *

State *

ZIP *

Primary Contact *

Title *

Email *

Office Phone *

Mobile Phone *

The applicant consents to receive SMS text messages from FacilityCare at the mobile number provided, including operational and onboarding communications. Message and data rates may apply.

Service Lines *

Full-Time Employees *

Part-Time / Seasonal *

Equipment (optional — counts optional, confirmed at screening)

Diversity Certifications

Company Description

States You Service *

Counties *

Mutual Aid — surge during major events? *

Furthest travel for mutual aid

Applicant summary

Reference 1 *

Name *

Company *

Phone *

Relationship *

Reference 2 *

Name *

Company *

Phone *

Relationship *

Prior relationship with East Coast Facilities or FacilityCare? *

How did you hear about FacilityCare? *

Attestation

Affirmed by (applicant name) *

Their title *

This application is entered on behalf of the named individual, who affirmed the information provided is accurate and complete.

Applicant summary

Thanks for your submission!