Enclosure 5 - Vendor ACH Authorization Form.pdf
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- Solicitation number
- 467862
- Issued by
-
Department of Energy Office of Science
About this file
This document is a Vendor ACH Authorization Form from Brookhaven National Laboratory, managed by Brookhaven Science Associates, LLC under contract with the U.S. Department of Energy. The form is designed to collect vendor banking information to facilitate electronic payments through the Automated Clearing House (ACH) system. It requires vendors to provide their company details, including vendor number and tax ID, as well as their financial institution's routing number and checking account information. The form includes an authorization section where the vendor's authorized representative can approve ACH credit entries, with the understanding that the authorization remains in effect until written notification is provided to terminate or modify it, in accordance with NACHA law.
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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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