Enclousure D - ACH Authorization Form.pdf

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Attached to
BOILER TUBES
Solicitation number
IO450547
Issued by

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This document is a Vendor ACH Authorization Form that allows Brookhaven National Laboratory/Brookhaven Science Associates to make payments to a vendor via Automated Clearing House (ACH) credit entries. The form requires the vendor to provide their company name, tax ID number, financial institution details including routing number and account number, and the name and contact information of an authorized representative. The authorization allows BNL/BSA to initiate ACH credit entries or correcting entries to the specified account until written notification is provided to terminate or modify the authorization.

The related federal contract opportunity is for the procurement of BOILER TUBES. The solicitation number is IO450547, and the opportunity is being issued by the Department of Energy Office of Science. All questions regarding this solicitation must be emailed to iorlando@bnl.gov by 4:30 PM on August 7, 2024, referencing the RFQ number in the subject line.

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Other files

File Type Posted
Enclousure B - Reps and Certs.pdf PDF
Enclousure F - W-8 Form (Foreign Vendors).pdf PDF
RFQ IO450547.pdf PDF
Enclousure C - Quatation Pricing Sheet.pdf PDF
Enclosure A - Draft PO.PDF PDF
Enclousure E - W9 Form (Domestic Vendors).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 .