FMS Vendor File Update Request Form.pdf
PDF 236 KB Posted
- Solicitation number
- 36C26225Q0092
About this file
This is a Vendor Information Form used by the VA to collect and verify vendor details before entering them into the VA database. The form requires comprehensive vendor information including business name, physical/mailing address, tax identification (TIN or SSN), contact details, payment information, and contract status.
The form includes several mandatory requirements: vendors must have a DUNS number (with registration at dnb.com if needed), must be registered in the Central Contractor Registration (CCR) system, and must be checked against exclusion databases (epls.arnet.gov and exclusions.oig.hhs.gov). The form also collects business classification information including size (small/large), socioeconomic categories (such as SDVOSB, WOSB, HUBZone), existing contract details, payment terms, and whether the vendor accepts purchase cards. This form appears to be associated with a courier transportation service solicitation (36C26225Q0092) for the Phoenix VA Healthcare System, though the form itself is a general vendor registration document.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 36C26225Q0092 0001.docx | DOCX document | |
| VA10091.pdf | ||
| W-9 Form.pdf | ||
| D.2 WAGE DETERMINATION.docx | DOCX document | |
| D1. SOW.docx | DOCX document | |
| D.4 Departmental Points of Contact.docx | DOCX document | |
| 36C26225Q0092_1.docx | DOCX document | |
| D.3 VENDORIZATION FORMS.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 .