J.8 - ACH Vendor Miscellaneous Payment Enrollment Form.pdf
PDF 249 KB Posted
- Attached to
- Tuberculosis Trials Consortium Services Federal contract opportunity
- Solicitation number
- 75D30120R67869
About this file
This document contains a vendor miscellaneous payment enrollment form and solicitation for tuberculosis clinical trial and research support services. The Centers for Disease Control and Prevention seeks to award a contract to support clinical trials and research on tuberculosis treatment, diagnosis and prevention from 2020 through 2030. Emphasis will be given to studies of latent tuberculosis infection in the United States as well as active tuberculosis disease domestically and internationally. Offerors are requested to provide banking information on the enrollment form for electronic funds transfer for future payments. The solicitation number is 75D30120R67869. The closing date and other submission requirements are not stated in this document.
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Text version
CDC OCFO 8/29/13
PRIVACY ACT STATEMENT
The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). All information collected on this form is required under the provisions of 31 U.S.C. 3322 and 31 CFR 210. This information will be used by the Treasury Department to transmit payment data, by electronic means to vendor's financial institution. Failure to provide the requested information may delay or prevent the receipt of payments.
VENDOR /MISCELLANEOUS PAYMENT
ENROLLMENT FORM
WIRE INFORMATION
AGENCY INFORMATION
FEDERAL PROGRAM AGENCY
CENTERS FOR DISEASE CONTROL & PREVENTION
ADDRESS
P. O. BOX 15580 MS D06
ATLANTA, GA 30333
CONTACT PERSON NAME: TELEPHONE NUMBER:
Customer Service (678) 475-4510
ADDITIONAL INFORMATION
FAX (404) 638-5342
PAYEE/COMPANY INFORMATION
PAYEE/COMPANY NAME:
ADDRESS:
CITY: COUNTRY : CODE:
CONTACT PERSON NAME: TELEPHONE NUMBER :
VENDOR'S LOCAL FINANCIAL INSTITUTION INFORMATION
BANK NAME:
BANK ADDRESS:
SWIFT CODE: SORT CODE:
ACCOUNT NUMBER:
BENEFICIARY NAME:
CURRENCY TYPE:
Please check with your bank for any additional information required to accept funds for this account
CLABE# (if required):
DUNS+4 NUMBER
rcr2 Typewritten Text
IIE3
Typewritten Text Attachment J.8 - Solicitation # 75D301-20-R-67869
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