Standard and Portal Billing Details for New Customers
Requestor Name
*
Full Name
Email
Company Name/Account Number
*
Company Name
Account Number. Hint: It starts with a D followed by six numbers.
FOR STANDARD BILLING
Billing Contact Information
Full Name
Email
Billing Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Billing Contact
Full Name
Email
Preferred Payment Method
Please Select
Check
Credit Card
ACH (if Billing is via a Portal, please complete Portal Section)
PO Number (if applicable)
PO Expiration Date
-
Month
-
Day
Year
Blanket PO? Please note: Culligan Quench prefers an Annual Blanket PO Number
Yes
No
FOR PORTAL BILLING
What payment portal system do you use?
Please Select
Ariba
Corrigo
Coupa
Merchant Ops
Nexus
OPS
Service Channel
Taulia
Tipalti
Tradeshift
Tungsten
Vendor Cafe
Not Listed/Other
Other Portal Payment System (if applicable)
PO Number
PO Expiration Date
-
Month
-
Day
Year
Blanket PO
Yes
No
Quench Supplier Number
*Please attach a document outlining how to submit invoices to your organization via the selected portal.
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Contact Name/Email for Portal Questions
Full Name
Email
Portal Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Thank you in advance for taking time to provide Culligan Quench with the correct and accurate billing process needed to ensure invoices are routed to the correct person or portal.
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