Enclosure D - Vendor ACH Authorization Form.pdf

This is a Vendor ACH Authorization Form utilized by Brookhaven National Laboratory, managed by Brookhaven Science Associates, LLC under contract with the U.S. Department of Energy. The form is a template designed to authorize electronic payment processing for vendor invoices.

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