Enclosure D - ACH Authorization Form.pdf

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Attached to
Bld. 902 Chiller Replacement
Solicitation number
AG449934
Issued by

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This document is an ACH Authorization Form for vendors to authorize Brookhaven National Laboratory/Brookhaven Science Associates to make payments via Automated Clearing House. It requires the vendor to provide their company information, financial institution details, and authorized representative contact information. The related federal contract opportunity is for the replacement of a Carrier Model 30RC Chiller at Building 902, to be completed by May 30, 2025. The solicitation number is AG449934 and is being issued by the Department of Energy Office of Science. All questions regarding this solicitation must be emailed to aghimiray@bnl.gov by 5:00 PM on July 29th, 2024.

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Other files

File Type Posted
Enclosure C - Quotation Pricing Sheet.pdf PDF
Solicitation No. 449934 - Amendment 1.pdf PDF
Enclosure A - SOW.pdf PDF
Enclosure F - W8 Form (Foreign Vendors).pdf PDF
RFQ No. 449934.pdf PDF
Enclosure G - W9 Form (Domestic Vendors).pdf PDF
Enclosure B - Draft Purchase Order.pdf PDF
Enclosure C - Quatation Pricing Sheet.pdf PDF
Enclosure E - Reps and Certs.pdf PDF

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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 .