B.1 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. The form is a template designed to collect vendor banking information for electronic payment processing.

The form requires vendors to provide identification information including company name or DBA, vendor number (if applicable), and Tax ID Number. Vendors must then supply depository information consisting of their financial institution name, routing/transit/ABA number, and checking account number. By signing the authorization section, 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 to terminate or modify it, and may only be revoked in accordance with NACHA (National Automated Clearing House Association) law. The form requires the authorized representative's name, email, phone number, signature, and date of authorization.