Enclosure 4 - Vendor ACH Authorization Form.pdf
PDF 136 KB Posted
- Solicitation number
- 458368CE
- Issued by
-
Department of Energy Office of Science
About this file
This is a Vendor ACH Authorization Form from Brookhaven National Laboratory (BNL), managed by Brookhaven Science Associates, LLC under contract with the U.S. Department of Energy. The form is designated as Enclosure 4 and is used to set up automated payment processing for vendors.
The form requires vendors to provide their company information (name/DBA, vendor number, and Tax ID), depository information (financial institution, routing/ABA number, and checking account number), and authorization details. The authorization section includes language permitting BNL/BSA to initiate ACH credit entries and corrections to the specified account, with the authorization remaining in effect until written notification of termination is received. The form must be signed by an authorized representative who must provide their email, phone number, and signature with date.
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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 .