Enclosure D. Vendor ACH Authorization 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 that authorizes BNL/BSA to initiate Automated Clearing House (ACH) credit entries and correcting entries to a vendor's designated bank account for payment purposes. Vendors must complete the Vendor Information section, which includes the company name or DBA, vendor number (if applicable), and Tax ID Number (TIN). The Depository Information section requires the financial institution name, routing/transit/ABA number, and checking account number. The authorization statement confirms that the vendor understands credit authorizations may only be revoked through written notification to the originator in accordance with NACHA (National Automated Clearing House Association) law, and the authorization remains in effect until BNL/BSA receives written termination or modification notice. The form must be signed by an authorized representative, who should also provide their email address, phone number, and the date of signature.