Company Name:  

Mailing Address:  
   
Mailing Address (cont.):  

City:                                                                   State:           Zip Code: 
     

Website:


Business Contact: 

Phone:                                                Fax:
   
Email:

EDI Technical Contact:

Phone:                                                Fax:
   
Email:

What type of Trading Partner are you?   Wholesaler Distributor Retailer Vendor Broker    Other:

What Third Party Network Provider will you be using?

What standard will you be using?     ANSI X.12 UCS   Other:  

What version will you be trading?    4010 4030 5010 5030   Other:   

Which documents will you be trading?
  810          856          880
  850          864          888
  852          875          997
  855          879        Other:  

TEST:
Test EDI ISA ID Qualifier:  

Test ISA ID:  

Test GS ID:  

Duns Number:  
 

PRODUCTION:
EDI ISA ID Qualifier:  

ISA ID:  

GS ID:  

Duns Number:  

Are Acknowledgements sent immediately on transmission to you?
  Yes            No