Industry Liaison Program Vendor Profile

Business Name

Business Website Address

Business Street Address

City

State

County

ZIP Code

Date of Incorporation/Inception

This field cannot be a future date.

Point of Contact

Point of Contact Title

Point of Contact Email

Point of Contact Phone Number

Alternate Point of Contact

Alternate Point of Contact Title

Alternate Point of Contact Phone

Alternate Point of Contact Email

Which disaster are you interested in supporting?

Hurricane Ian (DR-4673-FL)

Hurricane Fiona (DR-4671-PR)

Other

Other Disaster

Cage Code

Commercial and Government Entity (CAGE) Code:
This code is assigned through System for Award Management (SAM). If you have not registered, please go to http://www.sam.gov to register prior to completing this form.

Unique Entity Identifier (UEI)

NAIC Code(s)

Limit 5, separated by comma(s).

Is your product(s) or service currently on GSA schedule?

Yes

Is your company currently doing business with FEMA?

Yes

If yes, please list the name of the FEMA office(s)/person(s):

Please provide a brief description of your commodity(s)/service(s).

Does your company accept government purchase cards?

Yes

Reason for contacting FEMA:

General Inquiry

Vendor Presentation Meeting

Industry Day

Other

Have you previously met with a program office or FEMA representative in the last twelve (12) months?

Yes

If yes please provide that office(s)/person(s) name:

How did you find out about Industry Liaison?

Website

FEMA Small Business

FEMA Representative Referral

Other

FEMA Representative Referral Name

Completed by Name

Name of person completing the form.

Completed by Email

Email address of person completing the form.

PRIVACY ACT STATEMENT

AUTHORITY: 6 U.S.C § 796 "Registry of disaster response contractors" Purpose: DHS/FEMA collects this information to facilitate communication between FEMA and the participants of FEMA's Industry Liaison Program.

Routine Use(s): This information is used for the principal purpose(s) noted above. The information on this form may be disclosed internally within DHS as generally permitted under 5 U.S.C. § 552a(b)(1) of the Privacy Act of 1974, as amended, and will not be shared outside of DHS.

Disclosure: The disclosure of information on this form is voluntary; however, failure to provide the information requested may delay or prevent FEMA's sharing of information related to its Industry Liaison Program.

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