ANL-1094.pdf

41 KB Posted

Attached to
WATER COOLED FILTER UNIT
Solicitation number
4-B168-Q-00513-00
Issued by

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This document is an Electronic Transfer Authorization Form ANL-1094 used by Argonne National Laboratory to set up electronic payments to vendors. The form collects the vendor's financial institution information, including the bank name, routing number, and account number. It also requires the vendor's company information such as name, remittance address, and contact details. The completed form authorizes Argonne to initiate credit entries and make adjustments to the vendor's account. The authorization remains in effect until written notification is provided to terminate it.

The related federal contract opportunity is a solicitation from the Department of Energy Office of Science for two water-cooled filter assemblies to be incorporated into 8-inch CF flanges. Each filter assembly comprises two motorized, water-cooled pads housing three absorber units with thermocouples to monitor temperature. The solicitation number is 4-B168-Q-00513-00, and the opportunity type is a solicitation.

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Electronic Transfer Authorization Form

ANL-1094 (02/04/2020)

Vendor Number (For Internal Use Only)

I hereby authorize Argonne National Laboratory managed by UChicago Argonne, LLC (Argonne) to initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit entries in error to the company’s account indicated below and the Financial Institution named below. This authorization will remain in effect until Argonne Accounts Payable Section receives written notification to terminate the authorization. Please allow 30 days for processing changes.

New forms must be submitted for any changes and/or cancellations to any of the information indicated on this form.

Return completed form to one of the destinations below. If choosing email, please do not send over unsecure connections.

Secure email:

paymentforms@anl.gov

Secure Fax:

630-252-8270

Argonne National Laboratory Cashier 9700 South Cass Avenue, Bldg 201 Lemont, IL 60439

Financial Institution Information Financial Institution Name:

Institution Address:

Institution City / State / Zip / Country (req’d if Int’l):

Telephone # (if necessary):

You may only setup one bank account for Electronic Payments:

Checking OR Savings Cancel Checking Cancel Savings

Routing Number / ABA # (Must be 9 Digits) / SWIFT

BIC:

Account # / IBAN:

Authorization Information Company Name or DBA:

Remittance Address:

City / State / Zip: Telephone #:

E-mail Address (For Remittance Advise):

Printed Name: Title:

Authorized Signature: Date:

(For Internal Use Only:)

Entered by: Date:

Print Sign mpshields Highlight mpshields Highlight mpshields Highlight mpshields Highlight mpshields Highlight mpshields Highlight mpshields Highlight mpshields Highlight mpshields Highlight mpshields Highlight mpshields Highlight

Financial Institution Name:
Institution Address:
Institution City State Zip Country reqd if Intl:
Telephone if necessary:
Checking: On
Cancel Checking: Off
Cancel Savings: Off
Company Name or DBA: name of the Individual
Remittance Address:
City State Zip:
Telephone:
Email Address For Remittance Advise:
Printed Name:
Title:
Authorized Signature:
Date:
Entered by:
Date_2:
Sign:
Savings: Off
Vendor Number:
Routing Number / ABA #:
Account # / IBAN:

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