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. The form is a template designed to authorize electronic payments through the Automated Clearing House (ACH) system.

The form requires vendors to provide three categories of information: vendor identification details (company name/DBA, vendor number if applicable, and Tax ID Number), depository information (financial institution name, routing/transit/ABA number, and checking account number), and authorization documentation. The authorized representative must sign and date the form, certifying that Brookhaven National Laboratory/Brookhaven Science Associates is authorized to initiate ACH credit entries and correcting entries to the specified account. The authorization remains in effect until BNL/BSA receives written notification to terminate or modify it, with revocation subject to NACHA (National Automated Clearing House Association) regulations. The form also requests the authorized representative's email and phone number for contact purposes.