B.1d_485362 - Enclosure D. Vendor ACH Authorization Form.pdf

This is a Vendor ACH Authorization Form issued by Brookhaven National Laboratory, managed by Brookhaven Science Associates, LLC under contract with the U.S. Department of Energy. The form is a template designed to authorize electronic payments to vendors via Automated Clearing House (ACH) credit entries.

The form requires vendors to provide identifying information including company name or DBA, vendor number if applicable, and Tax ID Number. Vendors must also supply depository information including the financial institution name, routing/transit/ABA number, and checking account number. By signing the authorization, vendors grant Brookhaven National Laboratory and Brookhaven Science Associates permission to initiate ACH credit entries or correcting entries to the specified account. The authorization remains in effect until written notification of termination or modification is received by BNL/BSA. The form notes that credit authorizations may be revoked only through notification to the originator as prescribed by NACHA (National Automated Clearing House Association) law. The authorized representative must provide contact information including email and phone number, along with a signature and date to complete the form.