24-15 emsCharts Agreement.pdf

emsCharts, Inc. 125 Warrendale Bayne Road STE100 Warrendale, PA 15086 Phone: 866-647-8282 Fax: 724-933-9333 www.emscharis.com Charts Accounts Payable Form Please fill out the form below, providing current information for invoicing and Accounts Payable for your agency, and return with your signed emsCharts Service Agreement. = Accounts Payable Contact Information: Contracted Service Name:* What is the name of the EMS Agency that is contracting with emsCharts, inc? Accounts Payable Dept: if different from Agency name. Fill out mailing information below if different from Agency mailing address. Mailing Address 1: Mailing Address 2: City, State, Zip: Invoicing Contact Information: To whom should invoices be sent? Name:* Phone:* Email:* Invoices are sent electronically to the email address provided above. Invoicing Terms: Frequency (please check one):* 0) Monthly 0 Annually Annual payments receive a 5% discount Does your agency require a Purchase Order number on invoices? O Yes O No If yes, is the Purchase Order for emsCharts attached? 0 Yes 0 No Please provide any additional information important for proper invoicing to your agency: 4836-1231-3121, v. 1 * Required information emsCharts, Inc.