Enclosure 4 - Vendor ACH Authorization Form.pdf
PDF 114 KB Posted
- Solicitation number
- 455740
- Issued by
-
Department of Energy Office of Science
About this file
This is a vendor ACH (Automated Clearing House) authorization form used by Brookhaven National Laboratory/Brookhaven Science Associates (BSA) for processing electronic payments to vendors. The form requires vendors to provide their company information (name/DBA, vendor number if applicable, Tax ID Number), banking details (financial institution name, routing/ABA number, checking account number), and authorization from a company representative including contact information and signature. The form authorizes BSA to initiate ACH credit entries and corrections to the specified account until written notification to terminate or modify is received.
This form is associated with RFQ 455740 for HVAC and Power Equipment rental at Brookhaven National Laboratory, which is operated by BSA under contract with the Department of Energy Office of Science. The form serves as a payment processing document for vendors who may be awarded work under this solicitation.
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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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