FMS Vendor File Update Request Form.pdf
PDF 270 KB Posted
- Solicitation number
- 36C26223Q1489
About this file
This document contains a vendor file update request form and details of a related federal contract opportunity for laser services. The vendor form requests information such as company name, address, tax identification number, points of contact, and payment details. It also asks whether the vendor has an existing contract and if so requests contract and expiration details. Additional questions cover 1099 status, business type, socioeconomic certifications, purchase card acceptance, DUNS number registration, CCR registration, and checks of exclusion lists.
The related federal opportunity is a solicitation from the Department of Veterans Affairs for laser services at the San Diego VA Medical Center. The solicitation number, title, opportunity type, and contracting agency are provided. No further opportunity details are included in the file.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| RFQ Amendment - 36C26223Q1489 0001 02.docx | DOCX document | |
| 36C26223Q1489 0001_1.docx | DOCX document | |
| VA10091.pdf | ||
| 36C26223Q1489_1.docx | DOCX document | |
| W-9 Form.pdf | ||
| RFQ - 36C26223Q1489.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 .