D. Vendor ACH Athorization Form - For information only.pdf

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Attached to
B400 Directors Office Furniture
Solicitation number
MH469585
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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 allows vendors to authorize electronic payments through the Automated Clearing House (ACH) system by providing their banking details, including financial institution, routing/transit number, and checking account number. The authorization remains in effect until Brookhaven National Laboratory receives written notification to terminate or modify it, in compliance with NACHA (National Automated Clearing House Association) guidelines. The form requires the vendor's company information, tax ID number, and an authorized representative's signature and contact details.

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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 .