B.1 Enclosure 5 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. The form is a template that enables vendors to authorize electronic payment processing through the Automated Clearing House (ACH) system.

The form requires vendors to provide identification information including company name or DBA, vendor number (if applicable), and Tax ID Number. Vendors must also supply depository information consisting of the financial institution name, routing/transit/ABA number, and checking account number. By signing the authorization, vendors grant BNL/BSA permission to initiate ACH credit entries and correcting entries to the specified account. The authorization remains in effect until written notification of termination or modification is received, 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 contact information (email and phone number) and the date of authorization.