4. Enclosure 3 - Bank Information.pdf

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Attached to
448526 for Request for Proposal for Electrical Supplies & Equipment ICPT Agreement
Solicitation number
448526
Issued by

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This document is a Vendor ACH Authorization Form for Brookhaven Science Associates, LLC (BSA) under contract with the U.S. Department of Energy (DOE). It provides instructions for vendors to authorize BSA to make payments via Automated Clearing House (ACH) credit entries to the vendor's bank account. The form collects the vendor's company information, financial institution details, and an authorized representative's signature to set up the ACH payment authorization.

The related federal contract opportunity is a Request for Proposal (RFP) issued by BSA for Integrated Contractor Purchasing Team (ICPT) Agreement(s) for Electrical Supplies & Equipment under contract with the DOE Office of Science. The solicitation number is 448526, and any questions must be directed to Maile Nichols at mnichols@bnl.gov. The RFP has been posted on the sam.gov website under RFP 445180.

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Managed by Brookhaven Science Associates, LLC under contract with the

U.S. Department of Energy

Vendor ACH Authorization Form

VENDOR INFORMATION

Vendor/Company Name or DBA:

Vendor Number (if Applicable):

Tax ID Number (TIN):

DEPOSITORY INFORMATION

Financial Institution:

Routing/Transit/ABA Number:

Checking Account Number:

AUTHORIZATION

I (we) hereby authorize Brookhaven National Laboratory/Brookhaven Science Associates to make payments by initiating ACH (Automated Clearing House) credit entries or correcting entries to the account indicated above and associated with the financial institution named above. This authorization will remain in effect until BNL/BSA receives written notification to terminate or modify the same. It is my (our) understanding that credit authorizations may be revoked only by notification of the originator as described by NACHA (National Automated Clearing House Association) law.

Authorized Representative:

Email:

Phone:

Signature: Date:

VendorCompany Name or DBA:
Vendor Number if Applicable:
Tax ID Number TIN:
Financial Institution:
RoutingTransitABA Number:
Checking Account Number:
Authorized Representative:
Email:
Phone:
Date:

File details come from the government source that posted it. Updated .