FMS Vendor File Update Request Form

VENDOR INFORMATION

1. REQUESTOR:

2. SERVICE:

3. EXTENSION:

4. VENDOR NAME:

Doing Business As/Legal Name:

5. VENDOR ADDRESS

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: :

Physical Location:
Mailing Address:
City:
State/Zip:

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
12. 1099 Vendor Indicator:  YES (Always YES except if FEDERAL Government) 13. Business Type (FPDS) (Must check one):  Small

Large

 NO

 Outside VA

Other Entities

14. Socioeconomic Group: (Please check all that apply)
 Sm Disadvantage Bus
 Javits-Wagner-O’Day

 Veteran-Owned Small Bus
 Veteran-Owned Large Bus
 Veteran-Service Disabled

 Hubzone Small Business
 Woman-Owned Small Business  Historically Black College & Univ./Min Institute  Woman-Owned Large Business  None of the other business

15. Purchase Card Accepted  YES

 NO

(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/