Enclosure 4 - ACH Authorization Form.pdf
PDF 114 KB Posted
- Attached to
- Forward HCal SiPMs
- Solicitation number
- 443822
- Issued by
-
Department of Energy Office of Science
About this file
This document is an Automated Clearing House (ACH) Authorization Form for Brookhaven National Laboratory (BNL) and Brookhaven Science Associates, LLC (BSA). The form provides instructions for vendors to authorize BNL/BSA to make payments to the vendor by initiating ACH credit entries to the vendor's bank account. The form requires the vendor to provide their company information, financial institution details, and authorized representative contact information. This form is related to a federal contract opportunity solicitation for Forward Hadronic Calorimetry Photomultipliers (Forward HCal SiPMs) to be used at the Electron-Ion Collider (EIC). The solicitation, issued by BSA under contract with the U.S. Department of Energy (DOE) Office of Science, invites vendors to submit quotes in accordance with the Request for Quote (RFQ) letter and supporting attachments.
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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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