Enclosure D. Vendor ACH Authorization Form.pdf

This is a Vendor ACH Authorization Form required 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 that enables vendors to authorize BNL/BSA to process payments via Automated Clearing House (ACH) credit entries and correcting entries to a designated bank account.

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 acknowledgment. The authorized representative must provide contact information (email and phone) and execute the form with a signature and date. The authorization remains in effect indefinitely until BNL/BSA receives written notification to terminate or modify it. The form emphasizes that credit authorizations may only be revoked through notification to the originator as outlined by NACHA (National Automated Clearing House Association) law.