Enclosure 5 - Vendor ACH Authorization Form.pdf

114 KB Posted

Attached to
Mechanical Services Basic Ordering Agreement (BOA)
Solicitation number
SJ472268
Issued by

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This is a Vendor ACH Authorization Form used by Brookhaven National Laboratory (BNL), managed by Brookhaven Science Associates, LLC under contract with the U.S. Department of Energy. The form is a template designed to collect vendor banking information for electronic payment processing.

The form requires vendors to provide identification information including company name or DBA, vendor number if applicable, and Tax ID Number (TIN). In the Depository Information section, vendors must supply their financial institution name, routing/transit/ABA number, and checking account number. The Authorization section establishes that the vendor authorizes BNL/BSA to initiate ACH (Automated Clearing House) credit entries and correcting entries to the designated account. The authorization remains in effect until BNL/BSA receives written notification of termination or modification, and can only be revoked through originator notification as prescribed by NACHA (National Automated Clearing House Association) law. The authorized representative must provide their name, email address, phone number, signature, and date to validate the authorization.

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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 .