D. Vendor ACH Auth Form.pdf

This is a Vendor ACH Authorization Form used by Brookhaven National Laboratory (BNL), managed by Brookhaven Science Associates, LLC under contract with the U.S. Department of Energy. The form is a template designed to establish electronic payment authorization for vendors conducting business with the laboratory.

The form collects vendor identification information including company name or DBA, vendor number if applicable, and Tax ID Number. It requires depository information including the financial institution name, routing/transit/ABA number, and checking account number. The authorization section permits BNL/BSA to initiate ACH (Automated Clearing House) credit entries and correcting entries to the vendor's specified account. The authorization remains effective until BNL/BSA receives written termination or modification notice, with the understanding that revocations follow National Automated Clearing House Association (NACHA) law. The form requires signature from an authorized representative along with their email, phone number, and date of authorization.