B.1d - Enclosure D. Vendor ACH Authorization Form

Managed by Brookhaven Science Associates, LLC under contract with the U.S. Department of Energy
Vendor ACH Authorization Form

VENDOR INFORMATION

Vendor/Company Name or DBA:
Vendor Number (if Applicable):
Tax ID Number (TIN):

DEPOSITORY INFORMATION

Financial Institution:
Routing/Transit/ABA Number:
Checking Account Number:

AUTHORIZATION

I (we) hereby authorize Brookhaven National Laboratory/Brookhaven Science Associates to make payments by initiating ACH (Automated Clearing House) credit entries or correcting entries to the account indicated above and associated with the financial institution named above. This authorization will remain in effect until BNL/BSA receives written notification to terminate or modify the same. It is my (our) understanding that credit authorizations may be revoked only by notification of the originator as described by NACHA (National Automated Clearing House Association) law.

Authorized Representative:
Email:
Phone:
Signature:

Date: