B1 Enclosure D ACH Authorization Form.pdf

This is a Vendor ACH Authorization Form used by Brookhaven National Laboratory (BNL), which is 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 their company identification information, including vendor/company name or DBA, vendor number if applicable, and Tax ID Number (TIN). Vendors must also supply depository information consisting of their financial institution name, routing/transit/ABA number, and checking account number. By signing the form, vendors authorize BNL/BSA to initiate ACH 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 vendors acknowledge that credit authorizations may be revoked only through notification to the originator in accordance with NACHA (National Automated Clearing House Association) law. The form requires signature, date, and contact information (name, email, and phone) from an authorized representative of the vendor.