T-REX-COR: Cancellation Form

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T-Rex Cancellation Form
Form Type: Generic Cancellation

Summary: This form is only used to cancel an existing T-Rex integration.
- All transaction fees incurred during the month of cancelation will be billed on the first of the following month.
- Please contact us with any questions at 908-900-4720 or by emailing us at help@t-rex.technology.
Instructions:
1. Enter All Required Fields.
2. Click on the Adobe Sign button and E-Sign your request to complete your request.
3. Our support team will review your request to verify your submission and identity. Once verified, our team will e-sign the document and then will reach out to you to schedule the next steps for your request.
Your Company Information
What is your Company Name?*
Enter the same name as entered on your PAAS Agreement.
Your Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Requestor Name*

First NameLast Name
Requestor Phone Number*
Requestor Title?*
Requestor Email*
example@example.com
Pharmacy & Pharmacy Information System
Please indicate which integration we are terminating.
What is the pharmacy's name?*
Requested Cancelation Date

MonthDayYear
Date
Pharmacy Contact Name*

First NameLast Name
Pharmacy Contact Title*
Pharmacy Contact Email Address*
example@example.com
Pharmacy Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the reason for cancelling service?*

Changing Delivery Service SolutionMerger/AcquisitionGoing Out Of BusinessCostNot happy with the T-Rex solution.Other
Please use this section to document any additional information you would like to communicate with our team.
Disclosures and Fees
- Client is responsible for any remaining E-POD transaction charges.
- E-POD Charge: An E-POD charge will be incurred when a driver completes proof of delivery at a delivery stop or nursing station. A driver performing a consolidated stop delivery will only incur 1 E-POD charge.
- Data Retention is based on a per Business Unit Basis. Client must select this method at the beginning of the implementation process. Any future change request will not take effect until the next billing cycle.
- Client agrees and absolves Company of any liability for Data Quality.
- By signing this form, you agree to all terms, conditions, and billing requirements as stated in your current PAAS agreement and this cancellation request.
Should be Empty:

T-Rex Cancellation Form

Your Company Information

Pharmacy & Pharmacy Information System