B.1d_476546 - 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 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. Vendors must also supply depository information consisting of the financial institution name, routing/transit/ABA number, and checking account number. By signing the form, the authorized representative authorizes Brookhaven National Laboratory/Brookhaven Science Associates to initiate ACH (Automated Clearing House) credit entries or correcting entries to the specified account. The authorization remains in effect until BNL/BSA receives written notification of termination or modification, and vendors understand that credit authorizations 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.