Attachment E ACH Authorization.pdf
PDF 114 KB Posted
- Attached to
- X-ray Reflectometer
- Solicitation number
- 481221
- Issued by
-
Department of Energy Office of Science
About this file
This is a Vendor ACH Authorization Form used by Brookhaven National Laboratory (BNL), managed by Brookhaven Science Associates, LLC under contract with the U.S. Department of Energy.
The form is a template designed to authorize BNL/BSA to process vendor payments through Automated Clearing House (ACH) credit entries and correcting entries. Vendors must complete three sections: Vendor Information (including company name or DBA, vendor number if applicable, and Tax ID Number), Depository Information (specifying the financial institution, routing/transit/ABA number, and checking account number), and Authorization (where an authorized representative provides signature, date, email, and phone contact information). The authorization remains in effect until BNL/BSA receives written notification to terminate or modify it, and vendors acknowledge that credit authorizations may only be revoked in accordance with NACHA (National Automated Clearing House Association) law.
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Other files
| File | Type | Posted |
|---|---|---|
| Attachment G W-8.pdf | ||
| Quotation Sheet Attachment D.pdf | ||
| A.2 2026_SOW_XRR_703.pdf | ||
| B.1 RFQ 481221 Rev1.pdf | ||
| Draft PO Attachment A.PDF | ||
| Attachment F W-9.pdf | ||
| Attachment C AMS-FORM-050.pdf |
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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 .