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 vendors.

The form requires vendors to provide standard identification information including company name or DBA, vendor number if applicable, and Tax ID Number. In the Depository Information section, vendors must supply their financial institution details, including the routing/transit/ABA number and checking account number. By signing the authorization, vendors permit Brookhaven National Laboratory/Brookhaven Science Associates 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 of termination or modification, with credit authorizations subject to revocation only through notification of the originator as governed by 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.