NEW CUSTOMER MAINTENANCE FORM

NEW CUSTOMER MAINTENANCE FORM

NEW CUSTOMER Yes No

SAP CUSTOMER ACCOUNT NUMBER CUSTOMER TAX ID NUMBER CUSTOMER NAME

Change Delete

Address

Address

City

ADDITIONAL CONTACT NAME/NUMBER

SAP HEAD OFFICE ACCOUNT NUMBER (IF KNOWN)

Contact Name

Contact Email

Phone

State

Zip Code

Country

Fax

CUSTOMER INDUSTRY SERVICE MEDICAL RENTAL

SOURCE OF FUNDING FEDERAL STATE LOCAL

PRIVATE

INVOICE PAYMENT TERMS CONTRACT / CUSTOMER PO NUMBER

NOTES / INSTRUCTIONS FOR AR DEPARTMENT/DUNNING AREA-NUMBER

RESPONSIBLE PERSON (Person Completing Form) AUTHORIZED SIGNATURE (Manager/Director)

DATE DATE

PHONE PHONE

DEPARTMENT DEPARTMENT

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