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 designed to authorize electronic payments to vendors through the Automated Clearing House (ACH) system.

The form requires vendors to provide vendor information including company name or DBA, vendor number (if applicable), and Tax ID Number (TIN). Vendors must also supply depository information consisting of the financial institution name, routing/transit/ABA number, and checking account number. By signing the authorization, vendors grant BNL/BSA permission to initiate ACH credit entries and correcting entries to the designated account. The authorization remains in effect until BNL/BSA receives written notification to terminate or modify it, with revocation limited to originator notification as governed by NACHA (National Automated Clearing House Association) rules. The form requires the authorized representative to provide their name, email, phone number, signature, and date of authorization.