Industry Liaison Program Vendor Profile Form

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DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
INDUSTRY LIAISON PROGRAM
VENDOR PROFILE
CONTACT INFORMATION
2. Business Website Address
1. Business Name
5. State
6. County
7. Zip Code
3. Business Street Address
4. City
8. Date of Incorporation/Inception
9. Point of Contact
10. Point of Contact Title
12. Phone Number
13. Fax Number
11. Point of Contact E-mail Address
14. Alternate Point of Contact
15. Alternate Point of Contact Title
16. Phone Number
17. Fax Number
18. Alternate Point of Contact E-mail Address
Commercial and Government Entity (CAGE) Code: This code is assigned through System for Award Management (SAM). If you have not registered,
please go to
to register prior to completing this form.
1. CAGE Code:
2. DUNS Number:
3. NAIC Code(s) Maximum of 5
4. Please check all the categories that apply to your company.
8(a) Certified
Disadvantage/Minority
HBCU/Minority Institution
Historically Under Utilized Business Zone (HUB Zone)
Native American
Service Disabled Veteran Owned Small Business
Small Business
Small Disadvantaged Business
Tribal
Veteran Owned Small Business
Women Owned Small Business
Other
5. Is your product(s) or service currently on GSA schedule?
No
Yes
6. Does your company accept government purchase cards?
No
Yes
7. Is your company currently doing business with FEMA?
No
Yes
If yes, please list the name of the FEMA office(s)/person(s):
8. Reason for contacting FEMA:
General Inquiry
Vendor Presentation Meeting
Industry Day
Other
9. Have you previously met with a program office or FEMA representative in the last twelve (12) months?
No
Yes
If yes please provide that office(s)/person(s) name:
10. How did you find out about Industry Liaison?
Website
FEMA Small Business
FEMA Representative Referral
Other
Medical
Temporary
Infant Toddler
Water
Food
11. Please check applicable commodities(s)/service(s) your company provides:
Supplies
Housing/Shelter
Products
Generators
Blankets
Tarps
Cots
Other
12. Please provide a brief description of your commodity(s)/service(s).
I hereby affirm that the above information is true to the best of my knowledge. I further acknowledge that I have registered my company in System
for Award Management (SAM) prior to completing this form.
Date
Signature
NOTE: This correspondence or process does not promise, commit, or imply that a contract will be awarded.
FEMA Form 516-0-0-3, (11/12)

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