Enclosure D - 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 and suppliers.

The form requires vendors to provide identification information including company name or DBA, vendor number (if applicable), and Tax ID Number. Vendors must supply depository information consisting of their financial institution name, routing/transit/ABA number, and checking account number. By completing the authorization section, vendors authorize BNL/BSA to initiate ACH credit entries and correcting entries to their designated account. The authorization remains in effect until BNL/BSA receives written notification to terminate or modify it, with the understanding that credit authorizations may be revoked only through notification to the originator in accordance with NACHA (National Automated Clearing House Association) law. The form requires signature, date, and contact information from an authorized representative including name, email, and phone number.