Vendor Information 5-1-13.docx

VENDOR INFORMATION

1. REQUESTOR:

2. SERVICE:

3. EXTENSION:

4. VENDOR NAME:

Doing Business As/Legal Name:

5. VENDOR ADDRESS

Physical Location:

Mailing Address:

City:

State/Zip:

6. VENDOR TAX IDENTIFICATION NO. or

SOCIAL SECURITY NUMBER:

(Mandatory field must enter one or the other)

TIN:

SSN:

7. VENDOR PHONE & FAX NUMBER:

Phone:

Fax:

Email: :

8. PAYMENT STREET ADDRESS:

Address:

City:

State/Zip:

9. POINT OF CONTACT:

10. ACCOUNT NUMBER:

11. Does Vendor have an existing contract? |_|YES |_| NO If answer is YES, please enter Contract Number:

(i.e. GS-, V797 or any other contract with payment terms N/30 and expiration date) Beginning Date: Expiration Date:

FOB: |_|Destination |_|Origin Prompt Payment Discount: (i.e. 2%/10; 1%/20 or N/30)

12. 1099 Vendor Indicator: |_|YES (Always YES except if FEDERAL Government) |_| NO

13. Business Type (FPDS) (Must check one): |_| Small |_| Large |_| Outside VA |_| Other Entities

14. Socioeconomic Group: (Please check all that apply) |_| Sm Disadvantage Bus |_| Javits-Wagner-O’Day |_| Hubzone Small Business |_| Veteran-Owned Small Bus |_| Woman-Owned Small Business |_| Historically Black College & Univ./Min Institute |_| Veteran-Owned Large Bus |_| Woman-Owned Large Business |_| None of the other business |_| Veteran-Service Disabled

15. Purchase Card Accepted |_| YES |_| NO

16. DUN and BRADSTREET NUMBER: __________________________________ (Mandatory-if vendor does not have one they need to go to http://www.dnb.com to register.

17. Is Vendor registered with System for Award Management (SAM)? |_| YES |_| NO (Mandatory-if vendor is not registered they can accomplish the task at: http://www.sam.gov/ to register.

18. Before we may enter any new vendor information within the VA database the mandatory registration sites shall be checked along with the status of the vendor’s ability to do business within the Federal Government. Failure to check the mandatory field(s) could result in administrative action. The following two sites are your final check .

http://epls.arnet.gov/ & http://exclusions.oig.hhs.gov/

Local VA Form 10-5058 (90A) Revised May 2013