FMS Vendor File Update Request Form.pdf
PDF 236 KB Posted
- Solicitation number
- 36C26226Q0883
About this file
This is a Vendor Information Form used by the Veterans Affairs (VA) department to collect and validate vendor registration data for federal contracting purposes.
The form captures essential vendor identification details including requestor information, vendor name, business address, tax identification number (TIN) or Social Security Number (SSN), contact information, and payment address. It requires vendors to disclose existing contract information such as contract numbers, beginning and expiration dates, payment terms (FOB designation and prompt payment discounts), and 1099 vendor status. The form mandates completion of several fields critical to federal compliance: Business Type classification under FPDS guidelines (Small, Large, Outside VA, or Other Entities), Socioeconomic Group status (including Small Disadvantage Business, Veteran-Owned Small/Large Business, Woman-Owned Small/Large Business, HUBZone Small Business, Historically Black College/University/Minority Institute, and Veteran-Service Disabled), Purchase Card acceptance capability, Dun and Bradstreet Number, and Central Contractor Registration (CCR) status. The form establishes mandatory verification requirements that must be completed before vendor entry into the VA database, specifically requiring checks against the Excluded Parties List System (EPLS) at http://epls.arnet.gov/ and the HHS Office of Inspector General exclusions database at http://exclusions.oig.hhs.gov/ to confirm the vendor's eligibility to conduct business with the federal government.
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Other files
| File | Type | Posted |
|---|---|---|
| VA10091 Vendor Request Form.pdf | ||
| 36C26226Q0883_2.docx | DOCX document | |
| W9 Request for Taxpayer Identification Number and Certification.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 .