dataFM
This form tells us about the Organization that is obtaining the DataFM Wireless Address Channels. There could be several different payors for each Customer. For example, a city or county government might be the Customer but several different departments with separate budgets might acquire Information Channels. Then each department, or entity responsible for paying the account, would be a separate payor with a unique Account Number.

 CUSTOMER ACCOUNT INFORMATION

 

CUSTOMER                                  

CUSTOMER NUMBER             We will assign a Customer Number to your account                                  

ORGANIZATION

CONTACT PERSON         

ADDRESS LINE 1             

ADDRESS LINE 2              

CITY               ST              ZIP     

TAX ID NUMBER              

TELEPHONE                       

FAX                                       

EMAIL ADDRESS              

 

PAYOR INFORMATION           There can be several different Payors for each Customer

                                                                                       Complete a separate form for each different payor

ACCT NUMBER                                                  We will assign the Account Number.

ACCOUNT NAME                                                 Name of the entity responsible for payments    

AUTHORIZED PERSON NAME                         Who is the contact for billing and payment issues

AUTHORIZED PERSON TELEPHONE 

Check if Billing Address Same as Above           Check this box if appropriate, then skip the other blanks.

BILLING ADDRESS LINE 1                                  

BILLING ADDRESS LINE 2                      

CITY                   ST           ZIP   

 

_____________________________________             _____________________

            Signature of Authorizing Person                                      Date

There are two ways you can complete this form:

1. Click on the following link and open the Acrobat PDF file , fill in the form and fax it to us at 423-614-5595  

CLICK HERE FOR THE CUSTOMER INFORMATION FORM IN ADOBE ACROBAT (pdf) FORMAT                     

2. Click on the following link and a Word Document will open.  Complete the information online, save the file on your computer with your name and the word "Customer" (ex: SmithCustomer) and then email that form with the other forms to us at jvenable@datafm.com.

CLICK HERE FOR THE CUSTOMER INFORMATION FORM IN WORD Document FORMAT 

3. We will send you a confirmation when you account, Address Book and/or Wireless Address Channel are activated.