36C25820Q0181-032.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 Central Contractor Registration (CCR)? YES NO (Mandatory-if vendor is not registered they can accomplish the task at: http://www.ccr.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/