Enclosure 4 - Vendor ACH Authorization Form.pdf
PDF 136 KB Posted
- Attached to
- Amendment No. 1 to RFQ 446917CE Red-Dyed ULSD Heating Oil, Grade # 2 (Satellite Boilers)
- Solicitation number
- 446917CE
- 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) under contract with the U.S. Department of Energy. The form authorizes BNL/BSA to make payments to the vendor via Automated Clearing House (ACH) credit entries. It requires the vendor to provide their company information, financial institution details, and an authorized representative's signature.
The related federal contract opportunity is a Request for Quote (RFQ) from BNL/BSA for Red-Dyed ULSD Heating Oil, Grade # 2 (Satellite Boilers). The RFQ outlines the required product specifications and requests vendors to provide information on the origin of manufacture and their Unique Entity Identifier (UEI). Vendors are required to submit their quotes by 7/12/24. The resulting Purchase Order will be subject to the attached terms and conditions.
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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 .