Enclosure 4 - Vendor ACH Authorization Form.pdf
PDF 146 KB Posted
- Solicitation number
- 453288CE
- 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) to set up direct deposit payments for vendors. The form is associated with a solicitation for Liquid Helium supply for the Relativistic Heavy Ion Collider (RHIC) Campaign FY25.
The form requires vendors to provide their company information (name/DBA, vendor number, tax ID), banking details (financial institution, routing number, checking account number), and authorization signatures. It includes standard ACH authorization language allowing BNL/BSA to initiate credit entries and corrections to the specified account, with the authorization remaining in effect until written notification of termination is received. The form is managed under contract with the U.S. Department of Energy and requires an authorized representative's signature, email, phone number, and date.
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Other files
| File | Type | Posted |
|---|---|---|
| Questions_Answers Amendment 2.pdf | ||
| Questions_Answers 453288.pdf | ||
| RFQ Letter - 453288ce.docx | DOCX document | |
| Form W-8BEN-E (Rev. October 2021).pdf | ||
| Form W-9 (Rev. March 2024).pdf | ||
| Enclosure 3.pdf | ||
| Attachment A-SOW Revised.pdf | ||
| Enclosure 2 - AMS Form 050.pdf | ||
| Enclosure 1-Draft Contract.pdf |
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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 .