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. The form is a template that enables vendors to authorize electronic payment processing through the Automated Clearing House (ACH) system.

The form requires vendors to provide identifying information including company name or DBA, vendor number, and Tax ID Number. In the Depository Information section, vendors must supply banking details including the financial institution name, routing/transit/ABA number, and checking account number. The Authorization section grants BNL/BSA permission to initiate ACH credit entries and correcting entries to the specified account. The authorization remains in effect until written notification of termination or modification is received by BNL/BSA, and can only be revoked in accordance with NACHA (National Automated Clearing House Association) regulations. The form must be signed by an authorized representative and include contact information (email and phone number) and the date of authorization.