VA Form 10-0528 Vendor Application for Fair

OMB 2900-XXXX
Estimated Burden: 15 minutes

SOUTHEAST LOUISIANA VETERANS HEALTH CARE SYSTEM
VENDOR APPLICATION

SEND TO:

VHANOLMMSNewVendor@med.va.gov

FROM:

AGENCY:

PHONE NUMBER:

FAX NUMBER:

The following information must be provided when submitting your request. Complete the application
by selecting file; send to; mail recipient as attachment; to VHANOL MMS New Vendor@va.gov.

1. COMPANY NAME - NOTE: Do not abbreviations, and must be less than 35 characters

2. COMPANY ADDRESS - NOTE: PO Box address is not acceptable
STREET 1
STREET 2
CITY
STATE & ZIP CODE

3. PRODUCT INFORMATION - NOTE:
NAICS CODE
PRODUCT SERVICE
CODE
PRODUCT
DESCRIPTION

MANUFACTURER
DISTRIBUTOR

4. TELEPHONE NUMBER(S):

VA Form 10-0528
OCT 2011

5. FAX NUMBER(S):
6. FEDERAL TAX ID #:
Note: 9 Digits, no characters
7. POINT OF CONTACT:
FSS
GSA
OPEN MARKET

8. VENDOR TYPE:

COMMERCIAL
FEDERAL GOVERNMENT
INDIVIDUALS-OTHER

LARGE BUSINESS (500+ employees)
SMALL BUSINESS (less than 500 employees)
OUTSIDE U.S.
OTHER ENTITIES
WOMEN OWNED
MINORITY OWNED
VETERAN OWNED
SERVICE DISABLED VETERAN
VETERAN OWNED
DISADVANTAGED BUSINESS
10. SOCIOECONOMIC GROUP:
HUBZONE SMALL BUSINESS CONCERN
HISTORICALLY BLACK COLLEGES & UNIV
JAVITS-WAGNER-O’DAY (JWOD)
NONE OF THE OTHER CATEGORIES
11 DUNS (Data Universal Number System) number:
9. BUSINESS TYPE:

(Dun & Bradstreet number is MANDATORY if vendor does not have one, they need to go to http://www.dnb.com to
register
12. DOES THE VENDOR HAVE GOVERNMENT CONTRACT (i.e., General Service Administration or Federal Supply
Schedule)?
YES: Contract #
Contract Expiration Date:
NO

13. Is Vendor CCR registered:
http://www.ccr.gov)

Yes

No

(Please advise vendor to register at

COMMENTS (ANY SPECIAL REQUIREMENTS OR ADDITIONAL INFORMATION) :

This information is collected in accordance with section 3507 of the Paperwork Reduction Act of
1995. Accordingly, we may not conduct or sponsor, and you are not required to respond to a collection of
information unless it displays a valid OMB number. We anticipate that the time expended by all
individuals who complete this registration will average 15 minutes. This includes the time it will take to
read instructions, gather the necessary facts and fill out the form. The registration will serve as an
application to participate in Vendor Day activities and services. Completion of this form is voluntary.

VA Form 10-0528
OCT 2011