Enclosure 4 - Vendor ACH Authorization Form.pdf
PDF 136 KB Posted
- Solicitation number
- 446916CE
- Issued by
-
Department of Energy Office of Science
About this file
This document is a Vendor ACH Authorization Form from Brookhaven National Laboratory/Brookhaven Science Associates (BNL/BSA) managed under contract with the U.S. Department of Energy. The form provides instructions for vendors to authorize BNL/BSA to make payments via Automated Clearing House (ACH) credit entries to the vendor's designated checking account. It requires the vendor to provide their company information, financial institution details, and an authorized representative's signature to establish or modify the ACH payment authorization.
The related federal contract opportunity is for Clear ULSD Fuel Grade #2 Diesel, solicitation number 446916CE, issued by the Department of Energy Office of Science. BNL/BSA is seeking quotes for this fuel requirement and requests vendors provide the origin of manufacture and their Unique Entity Identifier (UEI). Quotes are due by 7/5/24. Any resulting purchase order will be subject to the attached terms and conditions.
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| Enclosure 5 W-9 Form (Domestic vendors).pdf | ||
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| BSA_Commercial_Items_Rev22_Sep_2022.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 .