Enclosure D - ACH Authorization Form.pdf
PDF 114 KB Posted
- Attached to
- Construction Manager as Advisor Federal contract opportunity
- Solicitation number
- 459544
- Issued by
- Department of Energy Office of Science
About this file
This is a Vendor ACH Authorization Form from Brookhaven National Laboratory (BNL), managed by Brookhaven Science Associates, LLC under contract with the U.S. Department of Energy. The form is included as Enclosure D in a solicitation for Construction Manager as Advisor Services for the Electron-Ion Collider (EIC) project.
The form requires vendors to provide their company information (including vendor name/DBA, vendor number if applicable, and Tax ID Number) and banking details (financial institution, routing/ABA number, and checking account number). The authorization section allows BNL/BSA to initiate ACH credit entries and corrections to the specified account, with the authorization remaining in effect until written notification of termination or modification is received. The form must be signed by an authorized representative who must also provide their email and phone contact information.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Questions and Answers RFQ 459544 3_24_2025.pdf | ||
| Questions and Answers RFQ 459544 3_17_2025.pdf | ||
| Questions and Answers RFQ 459544.pdf | ||
| Enclosure C - Quotation Pricing Sheet.docx | DOCX document | |
| Attachment A - Statement of Work 459544.pdf | ||
| Enclosure C - Quotation Pricing Sheet.docx | DOCX document | |
| Enclosure E - Form W-9.pdf | ||
| Enclosure F - Exhibit G-2 Staffing Plan.pdf | ||
| RFQ Letter 459544.pdf | ||
| Enclosure A - Draft Contract.pdf | ||
| Enclosure B - AMS-FORM-050 - Reps and Certs.pdf | ||
| Enclosure G - Exhibit G-4 Supplier Utilization Plan.pdf | ||
| Attachment B - BNL-QA-101 459544.pdf | ||
| Enclosure H - Exhibit G-6 Supplier Compliance and Payment Report.pdf |
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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: |
File details come from the government source that posted it. Updated .