Enclosure D - Vendor ACH Authorization Form.pdf

This is a Vendor ACH Authorization Form used by Brookhaven National Laboratory/Brookhaven Science Associates (managed under contract with the U.S. Department of Energy) to authorize electronic fund transfers to vendor accounts.

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 the financial institution name, routing/transit/ABA number, and checking account number. By signing the form, the vendor authorizes Brookhaven National Laboratory/Brookhaven Science Associates to initiate ACH (Automated Clearing House) credit entries or correcting entries to the designated account. The authorization remains effective until BNL/BSA receives written notification to terminate or modify it, and can only be revoked by notification to the originator in accordance with NACHA (National Automated Clearing House Association) law. The form requires signature and date from an authorized representative along with contact information including email and phone number.