Enclosure (D) Vendor ACH Authorization.pdf
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Department of Energy Office of Science
About this file
The document is a Vendor ACH Authorization Form for Brookhaven National Laboratory, managed by Brookhaven Science Associates, LLC under contract with the U.S. Department of Energy. The form is designed to collect vendor banking information to facilitate electronic payments through the Automated Clearing House (ACH) system. It requires vendors to provide their company details, including vendor/company name, vendor number, and tax ID number, as well as depository information such as financial institution, routing/transit number, and checking account number. The authorization section allows the vendor to grant Brookhaven National Laboratory permission to initiate direct credit entries to the specified bank account, with the understanding that the authorization remains in effect until written notification is received to terminate or modify it.
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Text version
Managed by Brookhaven Science Associates, LLC under contract with the
U.S. Department of Energy
Vendor ACH Authorization Form
VENDOR INFORMATION
Vendor/Company Name or DBA:
Vendor Number (if Applicable):
Tax ID Number (TIN):
DEPOSITORY INFORMATION
Financial Institution:
Routing/Transit/ABA Number:
Checking Account Number:
AUTHORIZATION
I (we) hereby authorize Brookhaven National Laboratory/Brookhaven Science Associates to make payments by initiating ACH (Automated Clearing House) credit entries or correcting entries to the account indicated above and associated with the financial institution named above. This authorization will remain in effect until BNL/BSA receives written notification to terminate or modify the same. It is my (our) understanding that credit authorizations may be revoked only by notification of the originator as described by NACHA (National Automated Clearing House Association) law.
Authorized Representative:
Email:
Phone:
Signature: Date:
| VendorCompany Name or DBA: |
| Vendor Number if Applicable: |
| Tax ID Number TIN: |
| Financial Institution: |
| RoutingTransitABA Number: |
| Checking Account Number: |
| Authorized Representative: |
| Email: |
| Phone: |
| Date: |
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