VA Form 10091.pdf
PDF 660 KB Posted
- Solicitation number
- 36C26224Q0900
About this file
This document is a VA Form 10091, which is the FMS Vendor File Request Form used to establish or update a vendor's information in the VA's financial system. It requires the vendor to provide details such as their DUNS number, TIN/SSN, NPI, business type, contact information, bank account details for electronic funds transfer, and confirmation of small business status if applicable.
The related federal contract opportunity is Solicitation 36C26224Q0900 for the replacement of boiler feed water system variable frequency drives, pumps, and motors at the Jennifer Moreno VA Medical Center in San Diego, CA. This is a SDVOSB set-aside solicitation under NAICS code 561210 with a $47M small business size standard. The response deadline is May 17, 2023 at 12:00 PM PDT. All questions must be submitted by May 8, 2023 at 3:00 PM PDT. The contracting office is the Department of Veterans Affairs, Network Contracting Office 22 in Long Beach, CA.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Boiler Feedwater System Questions and Answers 2.docx | DOCX document | |
| 36C26224Q0900 0003_1.docx | DOCX document | |
| 36C26224Q0900 0003.pdf | ||
| Boiler Feedwater System Questions and Answers.docx | DOCX document | |
| 36C26224Q0900 0002_1.docx | DOCX document | |
| 36C26224Q0900 0002.pdf | ||
| 36C26224Q0900 0001_1.docx | DOCX document | |
| RFQ - 36C26224Q0900 - Boiler Maintenance.pdf | ||
| W-9 Form.pdf | ||
| FMS Vendor File Update Request Form.pdf | ||
| 36C26224Q0900_1.docx | DOCX document |
Show all 11
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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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