Enclosure D - Vendor ACH Authorization Form.pdf

114 KB Posted

Attached to
Direct Wind Curing Oven
Solicitation number
MB447929
Issued by

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This document is a Vendor ACH Authorization Form from Brookhaven National Laboratory/Brookhaven Science Associates, which manages contracts with the U.S. Department of Energy. The form authorizes Brookhaven to make vendor payments via Automated Clearing House (ACH) credit entries to the vendor's specified checking account at their financial institution. The vendor must provide their company name, tax ID, financial institution details, and an authorized representative's contact information and signature to complete the authorization.

The related federal contract opportunity is for the procurement of a "Direct Wind Curing Oven" for the Department of Energy's Office of Science. The oven will be used for curing niobium titanium superconductor coils fabricated on stainless steel support tubes, with critical temperature uniformity requirements at 125°C, 175°C, and 225°C. The solicitation number is MB447929.

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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 .