IPS AAP - Pricing Trading Relationship Update [Test].

Test Form

updated 04/02/08

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Contact Name *
Contact Phone * (Area code)
Email Address *
Send Copy of Request * (CC for record)
* = Required Please allow 2 business days from for processing.

         
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 Effective Date
Carrier Member ID# Carrier Name
Distributor Member ID# Distributor Name
  >> ready to submit

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 Effective Date  [2]
Carrier Member ID# Carrier Name
Distributor Member ID# Distributor Name
  >> ready to submit

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Effective Date  [3]
Carrier Member ID# Carrier Name
Distributor Member ID# Distributor Name
  >> ready to submit

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 Effective Date  [4]
Carrier Member ID# Carrier Name
Distributor Member ID# Distributor Name
  >> ready to submit

        Please disregard this record
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 Effective Date  [5]
Carrier Member ID# Carrier Name
Distributor Member ID# Distributor Name
  >> ready to submit

        Please disregard this record
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 Effective Date  [6]
Carrier Member ID# Carrier Name
Distributor Member ID# Distributor Name
  >> ready to submit

        Please disregard this record
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 Effective Date  [7]
Carrier Member ID# Carrier Name:
Distributor Member ID# Distributor Name:
  >> ready to submit

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 Effective Date  [8]
Carrier Member ID# Carrier Name
Distributor Member ID# Distributor Name
  >> ready to submit

        Please disregard this record
Add
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 Effective Date  [9]
Carrier Member ID# Carrier Name
Distributor Member ID# Distributor Name
  >> ready to submit

        Please disregard this record
Add
Delete
Effective Date  [10]
Carrier Member ID# Carrier Name
Distributor Member ID# Distributor Name

Please allow 2 business days for processing from this date: .