D.3 FMS Vendor File Update Request Form 02.pdf
PDF 270 KB Posted
- Attached to
- J046--PMR Reverse Osmosis System - Base W/WD
- Solicitation number
- 36C26225Q0901
About this file
The document is a Vendor Information form used by the Department of Veterans Affairs (VA) to collect comprehensive vendor details for potential business engagement. The form requires vendors to provide key information including business name, contact details, tax identification, business type, socioeconomic group classification, payment information, and registration status with federal systems like Central Contractor Registration (CCR) and Dun & Bradstreet.
The form mandates vendors verify their eligibility to conduct business with the federal government by checking specific websites (http://epls.arnet.gov/ and http://exclusions.oig.hhs.gov/) and requires documentation of business characteristics such as size (small/large), socioeconomic status (e.g., veteran-owned, disadvantaged business), and payment acceptance methods. Vendors must also confirm their registration status and provide contact information, tax identification, and account details to be considered for potential contract opportunities with the VA.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C26225Q0901 0001.docx | DOCX document | |
| D.3 FMS Vendor File Update Request Form.pdf | ||
| D.3 W-9 Form.pdf | ||
| 36C26225Q0901_1.docx | DOCX document |
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Text version
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/
File details come from the government source that posted it. Updated .