S02 Attachment 2 FMS Vendor Update Form.docx
DOCX document 21 KB Posted
- Attached to
- S222--Hazardous Waste Removal Service Federal contract opportunity
- Solicitation number
- 36C26225Q0034_1
About this file
This document is a Vendor Information Form that must be completed by vendors interested in providing services to the Department of Veterans Affairs (VA) under Contract Number 36C26225Q0034_1 for Hazardous Waste Removal Service.
The form collects key vendor information including legal name, address, tax identification number, contact details, payment information, and details on any existing federal contracts. Vendors must indicate if they are a small, large, or other business type, and select any applicable socioeconomic classifications. The form also requires vendors to confirm registration in the Central Contractor Registration (CCR) and check exclusion lists prior to being added to the VA's vendor database. The related federal contract opportunity is for a firm fixed price, indefinite quantity, indefinite delivery contract to provide hazardous, non-hazardous, mixed and universal waste disposal services as well as pour-off, lab pack and removal services at the Southern Arizona VA Healthcare System in Tucson, Arizona.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C26225Q0034_1 QandA.docx | DOCX document | |
| 36C26225Q0034_1.docx | DOCX document | |
| S02 Attachment 1 W-9 Form.pdf | ||
| S02 Attachment 3 VA Form 10091 FMS Vendor.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 .