B1 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 procedures with vendors and suppliers.

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 their financial institution name, routing/transit/ABA number, and checking account number. By signing the authorization, vendors grant Brookhaven National Laboratory/Brookhaven Science Associates permission to initiate ACH (Automated Clearing House) credit entries or correcting entries to the specified account for payment purposes. The authorization remains effective until BNL/BSA receives written notification to terminate or modify it, with any revocation subject to NACHA (National Automated Clearing House Association) law requirements. The form requires signature from an authorized representative along with their email address, phone number, and the date of authorization.