Transfer Form

Phonak

Phonak Transfer Form

VENDOR RELEASE & AUTHORIZATION

(Company Name) hereby authorizes Phonak to open an exclusive account under the terms of their agreement with the “Audiology Practice Builders, LLC” business partnership. If the undersigned has an existing account with the vendor(s) checked below or one of their other buying partners this document serves as notification to change their existing account to an exclusive account under the terms of their agreement with the “Audiology Practice Builders, LLC” business partnership.

Location 1
APB Consultant's Name
APB Consultant's Email*
Current Bill To: Account Number
Current Ship To: Account Number
Company Name
DBA
Owner
First Last
Office Manager
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Fax
Email
Second Location
Current Bill To: Account Number
Current Ship To: Account Number
Company Name
Owner
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Fax
Email
Third Location
Current Bill To: Account Number
Current Ship To: Account Number
Company Name
Owner
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Fax
Email
Authorization
Signature*

Type your full name to sign.
Title
Today's Date
MM slash DD slash YYYY

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info@audiologypb.com

Transfer Form

Phonak Transfer Form

VENDOR RELEASE & AUTHORIZATION

Location 1

Second Location

Third Location

Authorization

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