36C25818Q9831-003.docx

FMS VENDOR FILE REQUEST FORM

NEW UPDATE

VA FACILITY INFORMATION

STATION NUMBER

STATION CONTACT

STATION PHONE NUMBER STATION FAX NUMBER

STATION EMAIL ADDRESS

PAYEE/VENDOR INFORMATION

COMMERCIAL VENDOR REGISTERED IN SAM.GOV

(Required IAW FAR 4.1102)

DUNS NUMBER

DUNS+4

SSN/TIN

PAYEE/VENDOR TYPE (Select one)

C - COMMERCIAL E - EMPLOYEE

F - FEDERAL AGENCY FACTS ID

O - FOREIGN

NPI

SMALL BUSINESS - VENDOR MUST BE QUALIFIED AS SMALL BUSINESS IN

I - INDIVIDUAL/HONORARIUM

V - VETERAN MISCELLANEOUS ACTIONS (Select one)

A - AGENT CASHIER U - UTILITY

VENDOR NAME

DBA

SAM OR FURNISH SBA CONFIRMATION

FOR QUESTIONS REGARDING THIS FORM:

NVF CONTACT INFORMATION

NATIONWIDE VENDOR FILE CUSTOMER SERVICE: EMAIL:

VAFSCVENDOT@VA.GOV

FOR ALL OTHER INQUIRIES:

CUSTOMER CARE CENTER: 1-877-353-9791 STATION CARE CENTER: 1-866-372-1141

SUBMIT ALL DOCUMENTATION VIA: SECURE FAX: 512-460-5221

CONTACT

EMAIL ADDRESS

PHONE NUMBER

CURRENT ADDRESSS (Include Street, City, State and Zip Code)

PREVIOUS ADDRESSS (Include Street, City, State and Zip Code)

EFT/ACH (Required IAW 31 CFR Part 208)

BANK NAME

BANK ADDRESSS (Include City, State and Zip Code)

NINE-DIGIT BANK ROUTING NUMBER

ACCOUNT NUMBER

ACCOUNT TYPE

CHECKING SAVINGS

PAYEE/VENDOR PRINTED NAME & TITLE

SIGNATURE

VA FORM APR 2014

10091

NORMAL PROCESSING TIME IS 3 - 5 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES

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