Enclosure D - ACH.pdf

This is a Vendor ACH Authorization Form used by Brookhaven National Laboratory to establish electronic payment capabilities for vendors providing goods or services.

The form requires vendors to provide basic 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 completing this form, vendors authorize Brookhaven National Laboratory/Brookhaven Science Associates to initiate ACH (Automated Clearing House) 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. The form requires signature from an authorized representative along with their email, phone number, and the date of authorization. Credit authorizations may only be revoked by notification of the originator as defined by NACHA (National Automated Clearing House Association) law.