36C25818Q9886-004.pdf

FSC VENDOR FILE REQUEST FORM

NEW UPDATE

VA FACILITY INFORMATION

STATION NUMBER

STATION CONTACT

STATION PHONE NUMBER STATION FAX NUMBER

STATION EMAIL ADDRESS

PAYEE/VENDOR TYPE (Select one)

C - COMMERCIAL

E - EMPLOYEE

I - INDIVIDUAL/HONORARIUM

V - VETERAN

F - FEDERAL AGENCY

O - FOREIGN

A - AGENT CASHIER

U - UTILITY

FACTS ID

MISCELLANEOUS ACTIONS (Select one) WINRS ASSIGNMENT (All applicable documents)

BILL OF COLLECTIONS SETTLEMENT/TORTS

ALAC/LGY ACCOUNT #

PAYEE/VENDOR INFORMATION

COMMERCIAL VENDOR REGISTERED IN SAM.GOV

(Required IAW FAR 4.1102)

DUNS NUMBER

DUNS+4

SSN/TIN

NPI

SMALL BUSINESS - VENDOR MUST BE QUALIFIED AS SMALL BUSINESS IN

SAM OR FURNISH SBA CONFIRMATION

VENDOR NAME

DBA

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

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

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

VA FORM

APR 2014 10091

Erica Perry-Johnson

(505)265-1711x3816

Erica.Perry-Johnson@va.gov