Form DS-4155 Vendor Application for OFM Website Account

*OMB APPROVAL NO. 1405-xxxx
EXPIRATION DATE: xx-xx-xxxx
ESTIMATED BURDEN: xx.

U.S. Department of State

VENDOR APPLICATION FOR OFM WEBSITE ACCOUNT
Fax completed application to OFM System Director fax 202-895-3669
Type of Request
New Account

Change to Existing Account

Delete Account

Country

Section 1 Vendor Applicant Information
1. Surname

2. Given Name

5. Telephone Number

6. E-mail Address

3. Middle Initial

4. Date of Birth (mm-dd-yyyy)

Section 2 User Acknowledgement
I understand that I am authorized to use this account only for the submission of requests to the U.S. Department of State, Office of Foreign
Missions that are solely associated with proposed purchases by the foreign mission(s) listed in Section 3 of this form and their eligible members
of tax and duty-free merchandise from bonded warehouse facilities in the United States. Any other uses of this account are strictly prohibited. I
will not divulge my login or password to any other entity. I will notify the Office of Foreign Missions if I have any reason to believe my password
has been compromised. I further acknowledge that improper use of this account could result in adverse administrative action against me.
Name

Signature

Telephone

Date (mm-dd-yyyy)

Section 3 Authorized Missions
Mission

City

State

ZIP Code

Section 4 Mission Administrative Officer Acknowledgement
I certify that the above named vendor is authorized to submit requests, to the U.S. Department of State, Office of Foreign Missions, (proposed
purchases by the foreign mission(s) listed in Section 3 and their eligible members), of tax and duty-free merchandise from bonded warehouse
facilities in the United States. I acknowledge that in the event I am made aware of any improper use of this account, I will provide all assistance
necessary to aid the Office of Foreign Missions with addressing the situation.
Printed Name

Title

Protocol Identification Number

Signature

Telephone Number

Email Address

Date (mm-dd-yyyy)
***Mission Seal Required***
Section 5 Office Of Foreign Missions Approval
Printed Name
DS-4155
xx-xxxx

Signature

Date (mm-dd-yyyy)
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Instructions for Completing Form DS-4155
VENDOR APPLICATION FOR OFM WEBSITE ACCOUNT
This form is to be completed when access to the U.S. Department of State, Office of Foreign Mission's e-Gov Bonded Warehouse program is being
requested by a vendor. This form must be completed by the bonded warehouse vendor as an account user to submit requests on behalf of the
authorized mission listed in Section 3 with the approval of the accredited mission administrative officer.
1. Type of Request.
Indicate whether this request is to:
a. Open a New Account
b. Change an Existing Account
c. Delete an Account
2. Section 1.
Enter complete name, date of birth, telephone number and e-mail address of vendor representative who will submit tax and duty-free
purchases of merchandise requests on behalf of the mission and/or eligible mission members.
3. Section 2.
Vendor completes this section to acknowledge that the purpose for the existence of this account is understood. Print and sign the name of the
vendor representative to be authorized access along with a contact telephone number and the date signed.
4. Section 3.
Enter the name of all the missions (by country), along with the mission type (e.g. embassy, consulate) on whose behalf the vendor
representative will submit such requests, as well as the city, state and zip code of their locations.
5. Section 4.
The administrative officer of the accredited mission completes this section to acknowledge authorization to have this application submitted by
the vendor on its behalf to the U.S. Department of State. Print and sign the name, title, PID number, telephone number, and e-mail address
of the authorized administrative officer. Also enter the date signed, with the mission seal in this section.
Paperwork Reduction Statement
PAPERWORK REDUCTION ACT: *Public reporting burden for this collection of information is estimated to average xx minutes per response,
including time required for searching existing data sources, gathering the necessary documentation, providing the information and /or documents
required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB control
number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: A/GIS/DIR,
Room 2400 SA-22, U.S. Department of State, Washington, DC 20522-2202.

Instruction Page 1 of 1