B.1 Enclosure D, Vendor ACH Authorization Form.pdf

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

The form collects vendor identification information including company name or DBA, vendor number (if applicable), and Tax ID Number. Under the Depository Information section, vendors must provide their financial institution details, including the 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, with revocation permitted only through notification as prescribed by NACHA (National Automated Clearing House Association) law. The form requires signature from an authorized representative along with their email, phone number, and date of authorization.