FMS Vendor File Update Request Form.pdf
PDF 236 KB Posted
- Attached to
- R499--POETRY THERAPY SERVICES
- Solicitation number
- 36C26224Q1825
About this file
This document is a Vendor File Update Request Form for a federal agency. The key details are:
The form is used to update vendor information in the agency's database, including vendor name, address, tax ID, payment address, point of contact, and existing contract details (contract number, dates, payment terms, FOB). The vendor must provide a DUNS number and confirm registration in the Central Contractor Registration (CCR) system. The vendor must also indicate their business type (small, large, etc.) and socioeconomic status (disadvantaged, HUBZone, veteran-owned, etc.). Finally, the vendor must confirm whether they accept purchase cards and whether they are on the Excluded Parties List System (EPLS) or Office of Inspector General exclusions list.
The related federal contract opportunity is for "POETRY THERAPY SERVICES" for the Department of Veterans Affairs Veterans Health Administration, Veterans Integrated Service Network 22. This appears to be a solicitation, but no additional details about the required products/services, response dates, pricing, or set-asides are provided in the given information.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C26224Q1825 0001.docx | DOCX document | |
| VA10091.pdf | ||
| 36C26224Q1825_1.docx | DOCX document | |
| D.3 VENDORIZATION FORMS.docx | DOCX document | |
| D.2 WAGE DETERMINATION.docx | DOCX document | |
| W-9 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 .