Change of Profile – Panasonic POS Client Portal

Customer Profile Change

This form allows customers to request changes to billing address or contact information.

Franchise(Required)

Current Billing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

New Address (check whether the address is different from the one above)(Required)

Changed

Same

New Billing Address(Required)

This field should be completed only if changing the billing address.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Contact Person(Required)

First Last

Email of Contact Person(Required)

Phone Number of Contact Person(Required)

Effective Date of Change

Enter the date from which this change applies (mm/dd/yyyy)

Thank you for your cooperation
Manager, Accounts Receivable

Name

This field is for validation purposes and should be left unchanged.