Dialog Customer Account Maintenance Form

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Customer Account Maintenance Form
Additional User Request

If you are adding several Users in multiple locations, please submit a separate form for each location.

* indicates that the information is required.
Note: If the Account number currently receives subscriber rates, the Information Provider must be contacted first. The Information Provider will notify Customer Administration.

Account Number:*

Requestor's Name:*

Company Name:*

Number of new Users for the location details shown below:*

Assigned User Name(s):*
(If requesting more than 5 new users for the same location, please enter additional names in the Comments section below.)

Department:

Location Details for New User(s)
(Please submit separate requests for new Users in separate locations.)

Address:*

City:*

State/Province/Region:*

Country:
(US & Canada)

Zip/Postal Code:*

Email:*

Telephone:*

Fax:

Additional Information

Product Selection:*

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Additional Comments:

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