Enclosure 4 - Vendor ACH Authorization Form.pdf
PDF 136 KB Posted
- Solicitation number
- 446918CE
- Issued by
-
Department of Energy Office of Science
About this file
This document is a Vendor ACH Authorization Form for Brookhaven National Laboratory/Brookhaven Science Associates (BNL/BSA). It provides instructions for vendors to authorize BNL/BSA to make payments to them via Automated Clearing House (ACH) credit entries. The form collects the vendor's company information, depository information including financial institution, routing/transit/ABA number, and checking account number. The vendor must provide an authorized representative's signature, email, and phone number to authorize this ACH payment method.
The related federal contract opportunity is for a Request for Quote (RFQ) for Red-Dyed ULSD Heating Oil, Grade # 2 (CSF) issued by the Department of Energy Office of Science. The RFQ includes a Draft Purchase Order with the requirements. Interested vendors must provide the origin of manufacture and their Unique Entity Identifier (UEI) in their quote. Quotes are due by 10/25/24. Any resulting Purchase Order will be subject to the attached terms and conditions.
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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:
Enclosure 4
File details come from the government source that posted it. Updated .