7 Enclosure (3) Vendor ACH form.pdf

This is a Vendor ACH Authorization Form used by Brookhaven National Laboratory (managed by Brookhaven Science Associates, LLC under contract with the U.S. Department of Energy) to establish electronic payment capabilities for vendor payments.

The form requires vendors to provide standard identification information including company name or DBA, vendor number (if applicable), and Tax ID Number. Vendors must supply depository information consisting of their financial institution name, routing/transit/ABA number, and checking account number. By signing the authorization, vendors grant Brookhaven National Laboratory/Brookhaven Science Associates permission to initiate ACH (Automated Clearing House) credit entries or correcting entries to the designated account. The authorization remains in effect until BNL/BSA receives written notification of termination or modification, with credit authorizations subject to revocation only through originator notification as governed by NACHA (National Automated Clearing House Association) law. An authorized representative must complete the form by providing their name, email, phone number, signature, and date.