VA Form 10091.pdf
VA Form PDF 660 KB Posted
- Solicitation number
- 36C26225Q0013
About this file
This document is the VA Form 10091, which is the FMS Vendor File Request Form used to provide new or updated vendor information to the Department of Veterans Affairs (VA). The form collects key details about the vendor such as their name, address, tax ID number, bank account information for Electronic Funds Transfer (EFT) payments, and indicates whether the vendor is registered in the System for Award Management (SAM). The form also allows the vendor to request various miscellaneous actions such as setting up a WINRS assignment or Bill of Collections account. The normal processing time for this form is 3-5 business days.
The attached related federal contract opportunity is Solicitation Number 36C26225Q0013 for DG10--TV SERVICE FOR ASPIRE CENTER - Base plus 4 OY (resolicit), issued by the Department of Veterans Affairs, Veterans Integrated Service Network 22. The solicitation seeks proposals for TV service at the Aspire Center. No other details about the required products or services, response dates, award information, set asides, or other key solicitation terms are provided in the information given.
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Other versions and copies of VA Form 10091
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Who attaches VA Form 10091
Other files
| File | Type | Posted |
|---|---|---|
| S06 36C26225Q0013 0001 Questions.pdf | ||
| 36C26225Q0013 0001_1.docx | DOCX document | |
| 36C26225Q0013_1.docx | DOCX document | |
| W-9 Form.pdf | ||
| CEP Registration Guidance -Venderization.pdf | ||
| S02 36C26225Q0013 Resolicitation.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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