Enclosure D - Vendor ACH Auth.pdf

114 KB Posted

Attached to
Assorted Steam Traps
Solicitation number
IO450315
Issued by

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This document is a Vendor ACH Authorization Form. It provides instructions for a vendor to authorize electronic payments from Brookhaven National Laboratory/Brookhaven Science Associates via Automated Clearing House (ACH) credit entries. The form requires the vendor to provide their company name, tax ID, financial institution details, and an authorized representative's contact information. The authorization allows BNL/BSA to make payments to the vendor's designated bank account until written notification is provided to terminate or modify the authorization.

The related federal contract opportunity is a Request for Quotes (RFQ) for Assorted Steam Traps, solicitation number IO450315, with a due date of 8/15/24 at 5pm. The RFQ is issued by the Department of Energy Office of Science. Interested vendors should submit their bids to iorlando@bnl.gov.

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Other files

File Type Posted
Enclousure A - Draft PO 450315.PDF PDF
Enclousure B - AMS 50 Reps and Certs.pdf PDF
Enclosure E - W9 Form (Domestic Vendor).pdf PDF
Enclousure C - Quatation Pricing Sheet.pdf PDF
Enclosure F - W8 Form (Foreign Vendor).pdf PDF
RFQ No IO450315.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 .