FMS Vendor File Update Request Form.pdf
PDF 236 KB Posted
- Solicitation number
- 36C26226Q0964
About this file
This is a Vendor Information form used by the Department of Veterans Affairs (VA) to collect and validate contractor data for the VA database. The form requires vendors to provide essential business information including company name, physical and mailing addresses, tax identification number or Social Security number, phone/fax contact details, and payment address. Vendors must identify their point of contact and account number while disclosing whether they hold an existing contract, including contract number, beginning date, expiration date, FOB terms, and prompt payment discount rates.
The form mandates completion of several compliance and registration fields to establish vendor eligibility for federal contracting. Vendors must indicate their 1099 status (always "YES" except for federal government entities), business type under FPDS classification (Small, Large, Outside VA, or Other Entities), and applicable socioeconomic categories such as Small Disadvantage Business, Veteran-Owned Small Business, Woman-Owned Small Business, HUBZone Small Business, Historically Black College/University, or Minority Institution status. Additionally, vendors must provide their Dun and Bradstreet number and confirm Central Contractor Registration (CCR) enrollment. The form emphasizes that before entering vendor information into the VA database, administrators must verify vendor status through two mandatory federal exclusion databases: the Excluded Parties List System (http://epls.arnet.gov/) and the HHS Office of Inspector General exclusions database (http://exclusions.oig.hhs.gov/). Failure to complete mandatory fields and perform these verification checks may result in administrative action.
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Other files
| File | Type | Posted |
|---|---|---|
| VA10091 Vendor Request Form.pdf | ||
| W9 Request for Taxpayer Identification Number and Certification.pdf | ||
| 36C26226Q0964_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 .