Enclosure D. ACH Authorization Form.pdf

114 KB Posted

Attached to
X-ray Refractive Lenses
Solicitation number
RFQ_464636
Issued by

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The document is a Vendor ACH Authorization Form for Brookhaven National Laboratory, managed by Brookhaven Science Associates, LLC under contract with the U.S. Department of Energy. The form is designed to authorize electronic payment processing through the Automated Clearing House (ACH) system, allowing the laboratory to initiate credit entries or make corrections to a vendor's specified bank account. The authorization remains in effect until Brookhaven National Laboratory receives written notification to terminate or modify the arrangement, in compliance with NACHA (National Automated Clearing House Association) regulations.

The form requires vendors to provide comprehensive financial and contact information, including vendor/company name, vendor number, tax ID number, financial institution details (routing/transit number and checking account number), and an authorized representative's contact information. This form is specifically associated with a Request for Quotation (RFQ_464636) for x-ray refractive lenses from the Department of Energy Office of Science, serving as a standard payment authorization document for potential contract vendors.

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Other files

File Type Posted
Attachment (B) BNL QA-101.pdf PDF
464636 - RFQ Document.pdf PDF
Enclosure B. AMS-FORM-050 (Annual Representations and Certifications).pdf PDF
Enclosure C. Quotation Pricing Sheet.pdf PDF
Attachment (A) Statement of Work.pdf PDF
Enclosure E. W-9 Form (REV 2024).pdf PDF
Enclosure A. Draft Contract 464636.pdf PDF
Enclosure F. W-8 BEN Form (Foreign).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 .