D. Vendor ACH Athorization 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 is a template requiring vendors to provide essential banking and organizational information to enable Automated Clearing House (ACH) credit entry payments.

The form requires vendors to complete three primary sections: Vendor Information (company name or DBA, vendor number if applicable, and Tax ID Number), Depository Information (financial institution name, routing/transit/ABA number, and checking account number), and Authorization. By signing the authorization section, vendors grant Brookhaven National Laboratory/Brookhaven Science Associates permission to initiate ACH credit entries and correcting entries to the specified account. The authorization remains in effect until BNL/BSA receives written notice of termination or modification, with revocation rights governed by NACHA (National Automated Clearing House Association) law. The form requires signature, date, and contact information (name, email, and phone number) from an authorized company representative.