9. Enclosure (5) 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 vendors.

The form requires vendors to provide standard identification information including company name or DBA, vendor number if applicable, and Tax ID Number (TIN). Under the Depository Information section, vendors must supply banking details including the financial institution name, routing/transit/ABA number, and checking account number. By signing the authorization, vendors grant BNL/BSA permission to initiate ACH (Automated Clearing House) credit entries and correcting entries to the specified account. The authorization remains in effect until BNL/BSA receives written notification to terminate or modify it, with revocation permitted only through notification procedures established by NACHA (National Automated Clearing House Association) law. The form requires signature and date from an authorized company representative, along with their email and phone contact information. This is a template form with blank fields for vendor completion.