B.1_RFQ 475671 - Enclosure D_Vendor ACH Authorization Form.pdf
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- Solicitation number
- 475671
- Issued by
-
Department of Energy Office of Science
About this file
This is a Vendor ACH Authorization Form used by Brookhaven National Laboratory/Brookhaven Science Associates for processing vendor payments through the Automated Clearing House system.
The form is a template that collects vendor identification information including company name or DBA, vendor number, and Tax ID Number. It requires depository information specifying the financial institution, routing/transit/ABA number, and checking account number where ACH payments will be deposited. The authorization section grants BNL/BSA permission to initiate ACH credit entries and correcting entries to the designated account. The authorization remains in effect until written notification is received to terminate or modify it, with revocation possible only through originator notification in accordance with NACHA (National Automated Clearing House Association) regulations. The form requires signature and date from an authorized representative, along with their email and phone contact information.
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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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