VA Form 10091.pdf
VA Form PDF 660 KB Posted
- Solicitation number
- 36C26224Q0381
About this file
This document is a VA Form 10091 - FMS Vendor File Request Form. It is used to register new vendors or update existing vendor information with the Department of Veterans Affairs (VA). The form collects vendor details such as name, address, contact information, bank account information for electronic funds transfer, and tax identification numbers. It also includes options for indicating the vendor type (e.g. commercial, employee, veteran) and miscellaneous actions (e.g. WINRS assignment, ALAC/LGY account). The normal processing time for this form is 3-5 business days.
The related federal contract opportunity is Solicitation Number 36C26224Q0381 for Emergency Eyewash Fountains Service and Repair, issued as a Service-Disabled Veteran-Owned Small Business (SDVOSB) set-aside. The work is for the VA San Diego Healthcare System and the North Carolina Contracting Office 22 is the contracting office. The NAICS code is 238220 with a $19 million size standard. Interested vendors must submit questions by March 25, 2024 and offers by March 27, 2024, both by 12:00 PM PST. No further questions or offers will be accepted after those dates.
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Who attaches VA Form 10091
Other files
| File | Type | Posted |
|---|---|---|
| 36C26224Q0381 0004.pdf | ||
| 36C26224Q0381 0004_1.docx | DOCX document | |
| IMG_0092.jpeg | JPEG file | |
| IMG_0091.jpeg | JPEG file | |
| IMG_0096.jpeg | JPEG file | |
| IMG_0094.jpeg | JPEG file | |
| IMG_0093.jpeg | JPEG file | |
| IMG_0095.jpeg | JPEG file | |
| 36C26224Q0381 0003.pdf | ||
| 36C26224Q0381 0003_1.docx | DOCX document | |
| Questions and Answers - 664 - Eyewash Station Repair and Maintenance.docx | DOCX document | |
| Site-visit Information.docx | DOCX document | |
| 36C26224Q0381 0002_1.docx | DOCX document | |
| 36C26224Q0381 0001_1.docx | DOCX document | |
| 36C26224Q0381 0001.docx | DOCX document | |
| FMS Vendor File Update Request Form.pdf | ||
| 36C26224Q0381_1.docx | DOCX document | |
| RFQ - 36C26224Q0381 Emergency Eyewash Station Repairs.pdf | ||
| W-9 Form.pdf |
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Text version
FMS VENDOR FILE REQUEST FORM
NEW UPDATE
VA FACILITY INFORMATION
STATION NUMBER
STATION CONTACT
STATION PHONE NUMBER STATION FAX NUMBER
STATION EMAIL ADDRESS
PAYEE/VENDOR TYPE (Select one)
C - COMMERCIAL
E - EMPLOYEE
I - INDIVIDUAL/HONORARIUM
V - VETERAN
F - FEDERAL AGENCY
O - FOREIGN
A - AGENT CASHIER
U - UTILITY
MISCELLANEOUS ACTIONS (Select one)
WINRS ASSIGNMENT (All applicable documents)
BILL OF COLLECTIONS SETTLEMENT/TORTS
ALAC/LGY ACCOUNT #
PAYEE/VENDOR INFORMATION
COMMERCIAL VENDOR REGISTERED IN SAM.GOV
(Required IAW FAR 4.1102)
DUNS NUMBER
DUNS+4
SSN/TIN
NPI
SMALL BUSINESS - VENDOR MUST BE QUALIFIED AS SMALL BUSINESS IN
SAM OR FURNISH SBA CONFIRMATION
VENDOR NAME
DBA
CONTACT
EMAIL ADDRESS
PHONE NUMBER
CURRENT ADDRESSS (Include Street, City, State and Zip Code)
PREVIOUS ADDRESSS (Include Street, City, State and Zip Code)
EFT/ACH (Required IAW 31 CFR Part 208)
BANK NAME
BANK ADDRESSS (Include City, State and Zip Code)
NINE-DIGIT BANK ROUTING NUMBER
ACCOUNT NUMBER
ACCOUNT TYPE
CHECKING SAVINGS
PAYEE/VENDOR PRINTED NAME & TITLE
SIGNATURE
NORMAL PROCESSING TIME IS 3 - 5 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES
FOR QUESTIONS REGARDING THIS FORM:
NVF CONTACT INFORMATION:
NATIONWIDE VENDOR FILE CUSTOMER SERVICE:
EMAIL: VAFSCVENDOT@VA.GOV
FOR ALL OTHER INQUIRIES:
CUSTOMER CARE CENTER: 1-877-353-9791
STATION CARE CENTER: 1-866-372-1141
SUBMIT ALL DOCUMENTATION VIA:
SECURE FAX: 512-460-5221
VA FORM
APR 2014 10091
FACTS ID
mailto:VAFSCVENDOT@VA.GOV
Bob Volck/Cassandra Wait
005/IT
10083, INFORMATION, TECHNOLOGY,
COMPUTER, ACCESS
Missie Vaccaro VA Form 10083, OFFICE OF INFORMATION TECHNOLOGY
COMPUTER ACCESS REQUEST FORM
AUGUST 2013
AUGUST 2013
\\iaimain\apps1\Pam_Ward\Logos\Formlogo.jpg Department of Veterans Affairs
FMS VENDOR FILE REQUEST FORM
F S C VENDOR FILE REQUEST FORM
VA FACILITY INFORMATION
VA FACILITY INFORMATION
STATION NUMBER
STATION CONTACT
STATION PHONE NUMBER
STATION FAX NUMBER
STATION EMAIL ADDRESS
PAYEE/VENDOR TYPE (Select one) MISCELLANEOUS ACTIONS (Select one)
PAYEE/VENDOR INFORMATION
PAYEE/VENDOR INFORMATION
DUNS NUMBER
DUNS+4
SSN/TIN
NPI
VENDOR MUST BE QUALIFIED AS SMALL BUSINESS IN
SAM OR FURNISH SBA CONFIRMATION
VENDOR NAME
DBA
CONTACT
EMAIL ADDRESS
PHONE NUMBER
CURRENT ADDRESSS (Include Street, City, State and Zip Code) PREVIOUS ADDRESSS (Include Street, City, State and Zip Code) EFT/ACH (Required IAW 31 CFR Part 208) E F T/A C H (Required I A W 31 C F R Part 208)
BANK NAME
BANK ADDRESSS (Include City, State and Zip Code)
NINE-DIGIT BANK ROUTING NUMBER
ACCOUNT NUMBER
ACCOUNT TYPE
PAYEE/VENDOR PRINTED NAME & TITLE
SIGNATURE
NORMAL PROCESSING TIME IS 3 - 5 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES
NORMAL PROCESSING TIME IS 3 - 5 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES
FOR QUESTIONS REGARDING THIS FORM:
NVF CONTACT INFORMATION:
NATIONWIDE VENDOR FILE CUSTOMER SERVICE:
EMAIL: VAFSCVENDOT@VA.GOV
FOR ALL OTHER INQUIRIES:
CUSTOMER CARE CENTER: 1-877-353-9791
STATION CARE CENTER: 1-866-372-1141
SUBMIT ALL DOCUMENTATION VIA:
SECURE FAX: 512-460-5221
FOR QUESTIONS REGARDING THIS FORM:
N V F CONTACT INFORMATION:
NATIONWIDE VENDOR FILE CUSTOMER SERVICE:
EMAIL: VAFSCVENDOT@VA.GOV
FOR ALL OTHER INQUIRIES:
CUSTOMER CARE CENTER: 1-8 7 7-3 5 3-97 91
STATION CARE CENTER: 1-8 6 6-3 7 2-11 41
SUBMIT ALL DOCUMENTATION VIA:
SECURE FAX: 5 1 2-4 6 0-52 21
VA FORM
APR 2014
V A FORM 1 0 0 9 1, APRIL 2014
10091
FACTS ID
| "UPDATE" CHECKBOX: 0 |
| "UPDATE" CHECKBOX: 0 |
| STATION NUMBER: |
| SIGNATURE: |
| ACCOUNT NUMBER LINE 2 OF 2: |
| ACCOUNT TYPE: "SAVINGS" CHECKBOX: 0 |
| ACCOUNT TYPE: "SAVINGS" CHECKBOX: 0 |
| ACCOUNT TYPE: "SAVINGS" CHECKBOX: 0 |
| COMMERCIAL VENDOR REGISTERED IN SAM.GOV (Required IAW FAR 4.1102) CHECKBOX: 0 |
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