Enclosure 4 - Vendor ACH Authorization Form.pdf

114 KB Posted

Attached to
Superconducting Strand - Direct Wind Magnets (Type 2)
Solicitation number
MB447904
Issued by

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This document is a Vendor ACH Authorization Form for Brookhaven National Laboratory/Brookhaven Science Associates. It authorizes the laboratory to make payments to the vendor via Automated Clearing House (ACH) credit entries. The form requires the vendor to provide their company information, financial institution details including routing/transit/ABA number and checking account number, and an authorized representative's contact information. Once submitted, this authorization will remain in effect until written notification is provided to terminate or modify the arrangement.

The related federal contract opportunity is a solicitation for the procurement of Type 2 Direct Wind Cable in accordance with the attached specification and statement of work. The solicitation number is MB447904 and the contracting agency is the Department of Energy Office of Science.

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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:

File details come from the government source that posted it. Updated .