FEMA INDUSTRY LIASON PROGRAM VENDOR REGISTRATION

Business Name *
Business Web Site
Address *
Street Address *
Address Line 2
City *
State / Province / Region *
Postal / Zip Code *
Country *
County *
NAIC Code(s) *
Please provide your company's Commercial And Government Entity (CAGE) Code assigned through Central Contractor Registration (CCR). If you have not registered, please go to www.ccr.gov to register. Your company must be registered with CCR before doing business with FEMA. *
DUNS Number *
Date of Incorporation/Inception (MM/DD/YYYY) *
Primary Point of Contact (POC) *
Primary POC Title *
Email Address *
Phone *

###
-
###
-
####
Fax Number

###
-
###
-
####
Alternate POC (if applicable)
Alternate POC Title
Phone

###
-
###
-
####
Fax Number

###
-
###
-
####
Reason for contacting FEMA *
 General Inquiry 
 Contact for the purpose of offering a product or service 
 Offering an unsolicited proposal 
 Follow-up 
 Vendor Day 
 Industry Day 
Your company may offer many products or services, but which specific product or service are you offering at this time? *
Which FEMA directorate or program office would your product or service apply to? List all offices that apply. *
Have you previously met with a program office or FEMA representative? If so, please provide the name of the office, the person that you met with, and the date of the meeting. *
Is your company currently doing business with a federal government entity or FEMA entity? If so, please list the name of the FEMA office/department and/or other federal agency. *
 YES 
 NO 
If your company is a small business, please check off all the categories that apply.
 8(a) Small Business  
 HBCU/Minority Institution 
 Historically Underutilized Business Zones (HUBZone) 
 Minority 
 Native American 
 Service Disabled Veteran Owned Small Business (SDVOSB) 
 Small Business (SB) 
 Small Disadvantaged Business (SDB) 
 Tribal 
 Veteran Owned Small Business (VOSB) 
 Woman Owned Small Business (WOSB) 
Is your product or service currently on a GSA schedule? If yes, please provide GSA schedule numbers. *
Do you accept government purchase cards? *
 YES 
 NO 
How did you find out about us (i.e. website, referral by FEMA representative, etc)? *
Any additional comments (200 words or less)