Enclosure D - Vendor ACH Authorization Form.pdf

This is a Vendor ACH Authorization Form issued by Brookhaven National Laboratory (BNL), managed by Brookhaven Science Associates, LLC under contract with the U.S. Department of Energy.

The form is a template used to establish electronic payment authorization for vendors conducting business with BNL. It requires vendors to provide standard identification information including company name or DBA, vendor number (if applicable), and Tax ID Number (TIN). The depository information section requests the vendor's financial institution details, including the routing/transit/ABA number and checking account number. By signing this authorization, vendors grant BNL/BSA permission to initiate ACH (Automated Clearing House) credit entries or correcting entries to the designated account for payment purposes. The authorization remains in effect until written notification of termination or modification is received by BNL/BSA, with credit authorizations subject to revocation only as described under NACHA (National Automated Clearing House Association) law. The form requires signature by an authorized representative, along with contact information including email and phone number, and must be dated upon execution.