446572 - RFQ_ACH Authorization Form.pdf
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- Attached to
- Liquid He Dewar and Sub-Cooler
- Solicitation number
- 446572
- Issued by
-
Department of Energy Office of Science
About this file
This is a Vendor ACH Authorization Form from Brookhaven National Laboratory (BNL), managed by Brookhaven Science Associates, LLC under contract with the U.S. Department of Energy.
The form is used to collect banking information from vendors to enable electronic payments via Automated Clearing House (ACH) transfers. It requires vendors to provide their company information (name, vendor number, tax ID), depository information (financial institution, routing number, account number), and authorization details including an authorized representative's signature. The form contains standard ACH authorization language referencing NACHA regulations and specifies that the authorization remains in effect until BNL/BSA receives written notification to terminate or modify it. This appears to be a standard payment processing form that would be required for any vendor doing business with BNL.
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Text version
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 .