Solicitation No.453282 - Enclosure 4 - Vendor ACH Authorization Form.pdf

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Attached to
Task Order Agreement for Cooling Tower Maintenance & Repair Services at Brookhaven National Laboratory
Solicitation number
SJ453282
Issued by

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This is a vendor ACH authorization form template required for payments from Brookhaven National Laboratory/Brookhaven Science Associates (BSA). The form collects vendor information including company name, vendor number, and tax ID, as well as banking details such as financial institution, routing number, and checking account number. The form authorizes BSA to make payments via ACH credit entries and requires an authorized representative's signature, email, and phone number.

This form is associated with solicitation SJ453282, a Task Order Agreement for cooling tower maintenance and repair services at Brookhaven National Laboratory in Upton, NY, managed by BSA under contract with the Department of Energy Office of Science. The form itself is a standard payment authorization template and does not contain specific details about the services or requirements of the cooling tower maintenance contract.

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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:

File details come from the government source that posted it. Updated .