Attachment D.3 - ACH Vendor Miscellaneous Payment Enrollment Form.pdf
PDF 249 KB Posted
- Solicitation number
- 75D30120Q71779
About this file
This document contains a vendor miscellaneous payment enrollment form and details of a related federal contract solicitation. The vendor payment enrollment form is for the Centers for Disease Control and Prevention and provides fields for payee and bank account information to enable electronic funds transfers.
Solicitation number 75D30120Q71779 is for tuberculosis trials consortium monitoring services. The Centers for Disease Control and Prevention's Office of Acquisition Services is seeking proposals to provide monitoring services for the Tuberculosis Trials Consortium. Offerors should review solicitation number 75D301-20-Q-71779 and all attachments for full requirement details, submission instructions, and response deadlines. The solicitation describes the required monitoring services but does not provide pricing, award date, or other contract terms.
View the file
Other files
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
CDC OCFO 8/29/13
PRIVACY ACT STATEMENT
The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). All information collected on this form is required under the provisions of 31 U.S.C. 3322 and 31 CFR 210. This information will be used by the Treasury Department to transmit payment data, by electronic means to vendor's financial institution. Failure to provide the requested information may delay or prevent the receipt of payments.
VENDOR /MISCELLANEOUS PAYMENT
ENROLLMENT FORM
WIRE INFORMATION
AGENCY INFORMATION
FEDERAL PROGRAM AGENCY
CENTERS FOR DISEASE CONTROL & PREVENTION
ADDRESS
P. O. BOX 15580 MS D06
ATLANTA, GA 30333
CONTACT PERSON NAME: TELEPHONE NUMBER:
Customer Service (678) 475-4510
ADDITIONAL INFORMATION
FAX (404) 638-5342
PAYEE/COMPANY INFORMATION
PAYEE/COMPANY NAME:
ADDRESS:
CITY: COUNTRY : CODE:
CONTACT PERSON NAME: TELEPHONE NUMBER :
VENDOR'S LOCAL FINANCIAL INSTITUTION INFORMATION
BANK NAME:
BANK ADDRESS:
SWIFT CODE: SORT CODE:
ACCOUNT NUMBER:
BENEFICIARY NAME:
CURRENCY TYPE:
Please check with your bank for any additional information required to accept funds for this account
CLABE# (if required):
DUNS+4 NUMBER
rcr2 Typewritten Text
IIE3
Typewritten Text Attachment D.3 - Solicitation # 75D301-20-Q-71799
| Payee Name: |
| EIN: |
| Address: |
| City: |
| Country: |
| Code: |
| Contact: |
| Phone: |
| Bank Name: |
| Bank Address: |
| Swift Code: |
| Sort Code: |
| Account #: |
| Bene Name: |
| Curr Type: |
File details come from the government source that posted it. Updated .