B.1_477787 - Enclosure D_Vendor ACH Authorization 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 processing for vendors.

The form captures essential vendor identification information including company name or DBA, vendor number, and Tax ID Number. It requires depository information consisting of the financial institution name, routing/transit/ABA number, and checking account number. The authorization section grants 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, and may only be revoked in accordance with NACHA (National Automated Clearing House Association) regulations. The form requires signature from an authorized representative along with their email, phone number, and the date of authorization. This is a standard template document used for vendor payment setup purposes.