Become Third Party Provider

Applicant Company

Company/Organization Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

URL Address

Company Phone

Primary Contact

Primary Contact Name(Required)

First Last

Primary Contact Title(Required)

Primary Contact Phone(Required)

Primary Contact E-Mail Address(Required)

Secondary Contact

Secondary Contact Name

First Last

Secondary Contact Title

Secondary Contact Phone

Secondary Contact E-Mail Address

Additional Company Information

Is your organization a…

If 'Other' please specify

Area(s) where you can currently provide services

Descriptive summary of your expertise and capabilities.(Required)

Are you a Certified Small Business?

Yes

Minority Business Enterprise Information

Are you eVA registered?

Yes

Approved third-party providers will be required to register with eVA. Information here: eVA Information

Do you have an active DoD or DoE Security Clearance?

Yes

If you answered 'Yes' to the previous question, what level?

Do you have professional liability insurance or the equivalent?

Yes

Liability amount $

If yes, please indicate the source of this insurance and its expiration date.

Professional Liability Insurance Source

Professional Liability Insurance Expiration Date

Geographic areas of Virginia in which you are willing to work on-site.

If remote work only, please indicate

Relevant and active memberships, certifications, licenses, awards, and other notable distinctions.

DAILY rate (or a range) that you normally charge clients for contract work.

The number of people your organization employs full time.

Number of years your organization has provided consulting services.

Number of years of industry experience of your organization.

Number of clients you've served as a consultant in the past 2 years.

REFERENCES

Please provide at least two references who we may contact concerning projects for which your organization served as a consultant. Please list references with projects that are as similar as possible to those you anticipate conducting through GENEDGE.

Reference 1

IMPORTANT – Your application will not be processed unless at least two references are provided.

Reference 1 Name(Required)

First Last

Reference 1 Title(Required)

Reference 1 Organization(Required)

Reference 1 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Reference 1 Email(Required)

Reference 1 Phone(Required)

Reference 1 Project Start Date

Reference 1 Project End Date

Reference 1 Project Description(Required)

Reference 2

Reference 2 Name(Required)

First Last

Reference 2 Title(Required)

Reference 2 Organization(Required)

Reference 2 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Reference 2 Email(Required)

Reference 2 Phone(Required)

Reference 2 Project Start Date

Reference 2 Project End Date

Reference 2 Project Description(Required)

Reference 3

Optional, but beneficial if Reference 1 or 2 is difficult to contact.

Reference 3 Name

First Last

Reference 3 Title

Reference 3 Organization

Reference 3 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Reference 3 Email

Reference 3 Phone

Reference 3 Project Start Date

Reference 3 Project End Date

Reference 3 Project Description

Wrap up

How did you first hear about GENEDGE?

I have read and agree to the Third-Party Provider Guidelines(Required)

Yes

Review the Third-Party Provider Guidelines (PDF) here.

CAPTCHA

Date

BECOME A THIRD-PARTY PROVIDER

Applicant Company

Primary Contact

Secondary Contact

Additional Company Information

REFERENCES

Reference 1

Reference 2

Reference 3

Wrap up