D. Vendor ACH.pdf

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Vertiv Products
Solicitation number
IO453527
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This document is a Vendor ACH Authorization Form that allows the vendor to authorize Brookhaven National Laboratory/Brookhaven Science Associates to make payments to the vendor's designated bank account via Automated Clearing House (ACH) credit entries.

The form requires the vendor to provide their company name, vendor number (if applicable), tax ID number, financial institution details including routing/transit/ABA number and checking account number, as well as the name, email, and phone number of the authorized representative. The vendor must sign and date the form to authorize the ACH payment arrangement, which will remain in effect until written notification is provided to terminate or modify it.

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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 .