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Facility Operator / M & R Vendor Registration
Facility Operator / M & R Vendor Registration
GENERAL DETAILS
Company Name
*
SCAC Code
First name
*
Middle name
Last name
*
Title
*
Email
*
Address Line1
*
Address Line2
Zip/Postal Code
*
City
*
State/Province
*
Country
*
Phone No.
*
Fax No.
*
Technical Contact Details same as above?
*
Yes
No
Billing Contact Details same as above?
*
Yes
No
TECHNICAL CONTACT DETAILS
First name
*
Middle name
Last name
*
Title
*
Email
*
Address Line1
*
Address Line2
Zip/Postal Code
*
City
*
State/Province
*
Country
*
Phone No.
*
Fax No.
*
BILLING CONTACT DETAILS
First name
*
Middle name
Last name
*
Title
*
Email
*
Address Line1
*
Address Line2
Zip/Postal Code
*
City
*
State/Province
*
Country
*
Phone No.
*
Fax No.
*
ACCOUNT ACCESS INFORMATION
Username
*
Password
*
Confirm Password
*
Category
*
M & R Vendor
FO
BOTH
I Agree to abide by the
terms and conditions
of IANA for DVIR.
Signed By
*
