468462 - Enclosure D_Vendor ACH Authorization Form.pdf
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- Solicitation number
- 468462
- Issued by
-
Department of Energy Office of Science
About this file
The document is a Vendor ACH Authorization Form from Brookhaven National Laboratory, managed by Brookhaven Science Associates, LLC under contract with the U.S. Department of Energy. The form is designed to authorize electronic payments through the Automated Clearing House (ACH) system, allowing the laboratory to make direct credit entries to a vendor's specified bank account. The authorization remains in effect until Brookhaven National Laboratory receives written notification to terminate or modify the arrangement, in compliance with NACHA (National Automated Clearing House Association) law.
The form requires vendors to provide comprehensive financial and contact information, including the vendor/company name, vendor number, tax ID number, financial institution details (routing/transit number and checking account number), and an authorized representative's contact information. The authorized representative must sign and date the form, officially granting Brookhaven National Laboratory permission to initiate and process electronic payments to the specified bank account.
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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: |
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