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 processing for vendor payments.

The form requires vendors to provide standard identification information including company name or doing business as (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 signing the 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 BNL/BSA receives written notification to terminate or modify it, with revocation possible only through notification of the originator as governed by NACHA (National Automated Clearing House Association) law. The form requires signature by an authorized representative along with contact information (email and phone) and the date of authorization.