Enclosure 4 - Vendor ACH Authorization Form.pdf
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- Attached to
- Amendment to RFQ 446912AB-Fuel Ethanol (E85)
- Solicitation number
- 446912AB
- Issued by
-
Department of Energy Office of Science
About this file
This document is an Automated Clearing House (ACH) Authorization Form for Brookhaven National Laboratory/Brookhaven Science Associates (BNL/BSA). It authorizes BNL/BSA to make payments to the vendor by initiating ACH credit entries to the vendor's checking account. The form includes the vendor's information, depository information, and authorization from the vendor's authorized representative.
The related federal contract opportunity is a Request for Quote (RFQ) issued by Brookhaven Science Associates, LLC (BSA) for Fuel Ethanol (E85) under a Prime Contract with the U.S. Department of Energy (DOE). The RFQ requires vendors to provide the origin of manufacture and Unique Entity Identifier (UEI), as well as a published price list and proof of registration in the System for Award Management (SAM). BSA will award the contract to the responsive and responsible offeror with the lowest total price. The pricing must remain valid for 60 days, and responses are due by 6/5/2024.
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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:
Enclosure 4
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