EmailMe Form - New Customer/Maintenance Form

Customer Maintenance

New Customer Information

Modify Customer Information

Software System to add new customer to: *

Quantum

Antera

Both Quantum & Antera

AMP Member Number *

Member's Email *

Customer Name *

Customer ID
(If Modifying)

Terms

Default terms are Net 10 unless noted differently above.

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Fax

### - ### - ####

Website

Tax Exempt ID

Taxable County

Merchant ID

If you have a custom Merchant ID, tell us what it is.

Secondary Consultant Split Commission

Primary Consultant

Secondary Consultant

Secondary Consultant % (if applicable)*

*Secondary Consultants will get a split of the Primary Consultant's commission in the amount specified.

Ship To Information

Ship To ID

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Fax

### - ### - ####

Tax Code

Taxable County

ACCT Payable Contact

Name

First Last

Title

Phone

### - ### - ####

Fax

### - ### - ####

Email

Purchasing Contact

Name

First Last

Title

Phone

### - ### - ####

Fax

### - ### - ####

Email

O/E Invoicing Contact

Name

First Last

Title

Phone

### - ### - ####

Fax

### - ### - ####

Email

Client specific comments or notes:

To Print

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