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 establish electronic payment capabilities for vendors.

The form is a template requiring vendors to submit vendor identification information including company name or DBA, vendor number if applicable, and Tax ID Number. Vendors must provide depository information including the financial institution name, routing/transit/ABA number, and checking account number. By signing the authorization, vendors grant BNL/BSA permission to initiate ACH (Automated Clearing House) credit entries and correcting entries to the designated account. The authorization remains effective until BNL/BSA receives written notification to terminate or modify it, with revocation procedures governed by NACHA (National Automated Clearing House Association) law. The form requires signature from an authorized representative along with contact information including email and phone number, and must be dated upon execution.