FMS Vendor File Update Request Form.pdf
PDF 270 KB Posted
- Attached to
- H146--Wastewater Sampling and Analysis, Chemical Oxygen Demand (COD) TEST SDVOSB SET ASIDE ONLY Federal contract opportunity
- Solicitation number
- 36C26225Q0480
About this file
This is a VA vendor information form used to collect and verify details about vendors seeking to do business with the Department of Veterans Affairs. The form captures essential vendor data including business name, address, tax identification information, contact details, and payment information.
The form requires vendors to specify their business type (Small, Large, Outside VA, or Other Entities) and any applicable socioeconomic designations such as Service-Disabled Veteran-Owned, Woman-Owned, or HUBZone small business. Vendors must provide their DUNS number and confirm registration in the Central Contractor Registration (CCR) system. Additional requirements include indicating 1099 vendor status, purchase card acceptance, and existing contract information including payment terms and FOB points. The form emphasizes mandatory registration and verification through multiple federal databases including epls.arnet.gov and exclusions.oig.hhs.gov to confirm vendor eligibility to conduct business with the federal government.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C26225Q0480_1.docx | DOCX document | |
| VA Form 10091.pdf | ||
| DELIVERY.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 .