D - Vendor ACH.pdf
PDF 114 KB Posted
- Attached to
- Odyssey Split System
- Solicitation number
- IO458794
- 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, LLC under contract with the U.S. Department of Energy. The form collects vendor information including company name/DBA, vendor number, and tax ID number (TIN), as well as depository information including financial institution details, routing/transit/ABA number, and checking account number.
The form authorizes BNL/BSA to initiate ACH credit entries and corrections to the specified account and includes fields for an authorized representative's signature, email, phone number, and date. The authorization remains in effect until written notification is received to terminate or modify it, with revocation possible only through notification of the originator as described by NACHA law. This form appears to be part of the vendor onboarding process for the Odyssey Split System procurement, which involves the purchase of three 7.5-ton HVAC units for the Department of Energy Office of Science.
View the file
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| File | Type | Posted |
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| A - Draft Purchase Order.PDF | ||
| Request for Quote.pdf | ||
| F - W8 Form.pdf | ||
| C- AMS 43 Quotation Pricing Sheet.pdf | ||
| E - New W9 form.pdf | ||
| B - AMS 50 Reps and Certs.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 .