Enclosure C - ACH Authorization Form.pdf
PDF 114 KB Posted
- Attached to
- Unit Sub-stations
- Solicitation number
- 438602
- Issued by
-
Department of Energy Office of Science
About this file
This document is an Automated Clearing House (ACH) Authorization Form for Brookhaven Science Associates, LLC (BSA) to make payments to vendors via direct deposit. The form requires the vendor to provide their company information, banking details, and an authorized signature to initiate ACH credit entries or corrections to the designated checking account. BSA operates Brookhaven National Laboratory under a prime contract with the U.S. Department of Energy.
The related federal contract opportunity is for the procurement of fifteen (15) skid-mounted secondary unit substations to be used at the Electron-Ion Collider (EIC) at Brookhaven National Laboratory. This solicitation has been set aside for Minority and Women-Owned Business Enterprises (MWBE). Vendors must submit a quotation and certify their MWBE status as defined by the state of New York. Any questions regarding this Request for Quote (RFQ) must be directed to Kevin Kirkendall at BSA by the date specified in the RFQ letter.
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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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