Enclosure D - Vendor ACH Authorization Form.pdf
PDF 114 KB Posted
- Attached to
- Professional Water Cooler Cleaning Services
- Solicitation number
- SJ452217
- Issued by
-
Department of Energy Office of Science
About this file
This is a Vendor ACH Authorization Form used by Brookhaven National Laboratory (BNL)/Brookhaven Science Associates (BSA) for setting up electronic payments to vendors. The form is associated with a solicitation for Professional Water Cooler Cleaning Services (Solicitation Number SJ452217).
The form requires vendors to provide their company information (name/DBA, vendor number, tax ID), banking details (financial institution, routing number, checking account number), and authorization signatures. The authorization allows BNL/BSA to initiate ACH credit entries and corrections to the specified account, with the agreement remaining in effect until written notification of termination is received. The form includes provisions regarding NACHA law compliance for credit authorization revocations and requires an authorized representative's signature, email, phone number, and date.
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Text version
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: |
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