Enclosure 4 - Vendor ACH Authorization Form.pdf

114 KB Posted

Attached to
Transition Radiation Tracker Support RFQ
Solicitation number
457907
Issued by

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This is a Vendor ACH Authorization Form used by Brookhaven National Laboratory (BNL)/Brookhaven Science Associates (BSA) for setting up electronic payments with vendors under their U.S. Department of Energy contract.

The form requires vendors to provide their company information (name/DBA, vendor number, tax ID), banking details (financial institution, routing/ABA number, checking account number), and authorization from a company representative. The form grants BNL/BSA permission to initiate ACH credit entries and corrections to the specified account, with the authorization remaining in effect until written notification is received to terminate or modify it. The form includes fields for the authorized representative's contact information (email, phone) and requires their signature and date.

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Other files

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1. RFQ Letter 457907.pdf PDF
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Enclosure 1 - Draft Award 457907 w Appendices.pdf PDF
Enclosure 2 - AMS Form 043 Pricing Sheet.docx DOCX document
Enclosure 3 - AMS-FORM-050 - Annual Representations and Certifications - Rev1.0.pdf PDF
Enclosure 6 - Form W-8 (Foreign Vendor).pdf PDF

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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 .