VA Form 10091.pdf
PDF 703 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 VA Form 10091, an FMS Vendor File Request Form used by the Department of Veterans Affairs to collect information from new vendors or update existing vendor information in their financial management system.
The form requires comprehensive vendor details including station information, payee/vendor type (with options for commercial, employee, veteran, federal agency, etc.), DUNS number, SSN/TIN, NPI number, and small business status verification from SAM.gov or SBA. It mandates EFT/ACH banking information as required by 31 CFR Part 208, including bank routing number, account number, and account type. The form specifies a normal processing time of 3-5 business days and provides contact information for the Nationwide Vendor File Customer Service (email: vafscvendot@va.gov) and Customer Care Center (1-877-353-9791). All documentation must be submitted via secure fax to 512-460-5221.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| W-9 Form.pdf | ||
| FMS Vendor File Update Request Form.pdf | ||
| DELIVERY.docx | DOCX document | |
| 36C26225Q0480_1.docx | DOCX document |
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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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