Enclosure D - Vendor ACH Authorization Form.pdf

This is a Vendor ACH Authorization Form used by Brookhaven National Laboratory (managed by Brookhaven Science Associates, LLC under contract with the U.S. Department of Energy) to establish electronic payment procedures with vendors.

The form requires vendors to provide identification 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 completing and signing this authorization, vendors grant Brookhaven National Laboratory/Brookhaven Science Associates permission to initiate ACH (Automated Clearing House) credit entries and correcting entries to the designated account. The authorization remains in effect until written notification of termination or modification is received by BNL/BSA. Vendors are advised that credit authorizations may only be revoked through originator notification in accordance with NACHA (National Automated Clearing House Association) law. The authorized representative must provide their name, email address, phone number, signature, and date to complete the form.