Enclosure (3) Vendor ACH Authorization Form.pdf
PDF 125 KB Posted
- Solicitation number
- RFQ_455376
- 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 (BNL/BSA) for setting up electronic payments to vendors. The form is associated with a solicitation for Twinax Cables for the DUNE project at Brookhaven National Labs.
The form requires vendors to provide their company information (name/DBA, vendor number if applicable, tax ID number) and banking details (financial institution, routing/ABA number, checking account number). It includes an authorization section where vendors authorize BNL/BSA to initiate ACH credit entries and corrections to the specified account. The authorization remains in effect until written notification is received to terminate or modify it, in accordance with NACHA regulations. The form must be signed by an authorized representative who must provide their contact information including email and phone number.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| RFQ No. 455376.pdf | ||
| Enclosure (4) W-9 Form.pdf | ||
| Attachment (A) Statement of Work.pdf | ||
| Attachment (B) BNL-QA-101.pdf | ||
| Enclosure (2) Pricing Sheet 455376.docx | DOCX document | |
| Enclosure (1) Draft Contract 455376.docx | DOCX document |
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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 .