Enclosure 4 - 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 processing for vendors.

The form requires vendors to provide essential identification and banking information, including company name or DBA, vendor number if applicable, and Tax ID Number (TIN). Vendors must supply depository information consisting of the 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 and correcting entries to the designated account. The authorization remains active until BNL/BSA receives written notification to terminate or modify it, with any revocation subject to NACHA (National Automated Clearing House Association) regulations. The form requires signature and date from an authorized representative along with their email address and phone number.