Enclosure D - Vendor ACH Authorization Form.pdf

This is a Vendor ACH Authorization Form used by Brookhaven National Laboratory/Brookhaven Science Associates for processing vendor payments through the Automated Clearing House (ACH) system. The form is a template designed to collect essential banking and authorization information from vendors conducting business with the laboratory.

The form requires vendors to provide their company name or DBA, vendor number (if applicable), and Tax ID Number. In the Depository Information section, vendors must supply their financial institution name, routing/transit/ABA number, and checking account number. The Authorization section contains standard language authorizing BNL/BSA to initiate ACH credit entries and correcting entries to the designated account. The authorization remains in effect until the vendor provides written notification to terminate or modify it, and vendors understand that credit authorizations may only be revoked through notification to the originator in accordance with NACHA (National Automated Clearing House Association) law. The form requires signature, date, and contact information (name, email, and phone number) from an authorized representative of the vendor.