Industry Liaison Program Vendor Profile

Format YYYY-MM-DD 
This field cannot be a future date.
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.
Limit 5, separated by comma(s).

Commodities section 1

Please select the primary commodity(s)/service(s) your company provides.

Commodities section 2

Building lease - Please specify:
Food/meals - Please specify:
Generators - Please specify:
Utilities - Please specify:
Water - Please specify:
Name of person completing the form.
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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