FMS Vendor File Update Request Form.pdf
PDF 236 KB Posted
- Solicitation number
- 36C26225Q0125
About this file
This document is a Vendor Information Form for the Department of Veterans Affairs to update vendor information in their database. It requires the vendor to provide details such as their name, address, tax ID or social security number, point of contact, payment details, and information on any existing federal contracts. The vendor must also indicate their business type, socioeconomic status, and whether they accept purchase cards. The vendor is required to register with the Central Contractor Registration (CCR) and check their status on the Excluded Parties List System (EPLS) and the Health and Human Services (HHS) exclusions list.
The related federal contract opportunity is a solicitation for hotel lodging services for the VA Long Beach Healthcare System at the Holiday Inn Long Beach Airport and Conference Center. It is a small business set-aside under FAR 19.5, with no substitutions allowed for small business concerns. The solicitation number is 36C26225Q0125.
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Other files
| File | Type | Posted |
|---|---|---|
| VA10091.pdf | ||
| W-9 Form.pdf | ||
| D.3 VENDORIZATION FORMS.docx | DOCX document | |
| 36C26225Q0125_1.docx | DOCX document | |
| D.2 WAGE DETERMINATION.docx | DOCX document | |
| D1. STATEMENT OF WORK.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 .