INVOICE DELIVERY METHOD - CHANGE FORM
Bill To Address Information
If there are multiple shipping locations linked to the bill-to address, the invoice preference selected will also be applied to all ship-to locations associated with the bill-to.
   
Customer # (optional):
Facility Name:*
Attn:
Address:*
City:*
State:*
Zip:*
Corporate Parent/Owner:
Affected Shipping Addresses
Please provide a list of all shipping addresses which should be linked with the provided Bill To address for invoicing purposes. These can be entered one-by-one in the area provided below, or can be provided via an attachment by clicking "Choose File", selecting the file you want to attach, and then clicking "Upload".

Invoicing Method and Signature
Please choose one of the following invoicing methods:
To ensure emails from Bracco Diagnostics Inc can be successfully received by your organization without being routed to Junk or Spam folders, please coordinate with your IT Department to add diag.bracco.com to your list of allowed email domains.
 
 
 
Signing Below represents and warrants to Bracco Diagnostics Inc. that he/she has full authority to sign such a document requesting the change on behalf of the bill-to account and all related ship-to accounts. Lack of authorization and/or incorrect submission of this form does not remove any customer obligations for timely payment of all invoices per the contracted or invoiced payment terms (as appropriate).
 
Name of Requestor:* Title of Requestor:*
Department of Requestor:* Phone Number of Requestor:
Email Address of Requestor:*

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