... Customer Code
Request Form for Customer ID Code
Use this form to request Customer ID codes or update an existing code for accounts receivable or invoice transactions.
Instructions:
Fill in the blanks with the appropriate information. At the end of this form, print it out and fax this information to the PAF Team at 713-500-4939.
Required fields are marked with **
Mark if new request:
Mark if change request:
Provider/Customer Information:
**Provider/Customer Name: (max. 10 characters)
** Recommended Short Name: (max.10 characters)
**Address Line 1:
**Address Line 2:
**Address Line 3:
** City: **State:
**Zip code: Country:
Provider/Customer Telephone Number:
Provider/Customer Fax Number:
**What is the reason for the request?
Your Information:
**Type name here:
Inter-institutional address:
Your Telephone Number:
** Your Fax Number:
Email username @ email Server
@** Your E-mail address:
Additional Information:
Administrative Use Only:
Location Sequence: (three numeric characters)
Location Description: (maximum 30 characters)
Entered/Updated By:
Date:
The University of Texas Health Science Center at Houston
Site maintained by Finance
Last updated January 30, 2009
