FMS Vendor File Update Request Form.pdf
PDF 236 KB Posted
- Solicitation number
- 36C26226Q0200
About this file
This document is a Vendor Information form used by the Department of Veterans Affairs (VA) for registering a new vendor in their database. The form requires comprehensive vendor details including business contact information, tax identification, business type, and socioeconomic status. Key requirements include mandatory registration on Central Contractor Registration (CCR) and Dun & Bradstreet, as well as verification checks on vendor eligibility through http://epls.arnet.gov/ and http://exclusions.oig.hhs.gov/.
The form captures critical vendor classification information such as business size (small/large), socioeconomic group (including small disadvantaged business, veteran-owned, woman-owned, HUBZone), payment terms, purchase card acceptance, and existing contract details. Additional mandatory fields include tax identification number, contact information, and confirmation of federal business registration status. The document emphasizes compliance checks and administrative procedures for adding new vendors to the VA's procurement system.
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| VA10091 Vendor Request Form.pdf | ||
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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 .