Testing Services Customer Information Form For Non-University Of Illinois Client

TESTING SERVICES CUSTOMER INFORMATION FORM FOR NON-UNIVERSITY OF ILLINOIS CLIENT

Principal Investigator Information

User Name(Required)

(Principal Investigator)

Institution Name(Required)

(Client)

Department(Required)

Client Billing Street Address(Required)

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

Email(Required)

Phone(Required)

Entity Type(Required)

Other Entity Type(Required)

Tax ID number (required for US institutions only)(Required)

Business Office Information

Contact Name(Required)

Name

Contact Email(Required)

Would you like any other email addresses to receive a copy of invoices?(Required)

Optional Email 1

Optional Email 2

Optional Email 3

Contract Signature Authority Information

Contact Name(Required)

Name

Contact Email(Required)

Contact Telephone(Required)

Contact Title(Required)

If a PO is to follow, send to Amanda Foltz or Sheena Marshall (cbc-admin@illinois.edu).