ACCOUNT UPDATE FORM - Panhandle Ace

Please print, complete, and return form to: pbetts@panhandleace.com or fax to: (850) 848-5809.  If you have any questions, please call (850) 520-2107.  

ACCOUNT NAME: _____________________________________________

ACCOUNT NUMBER: __________________________________________

REASON FOR UPDATE:    ___ USER CHANGE         ___ CONTACT PERSON CHANGE

                                         ___ CLOSE ACCOUNT    ___ INFORMATION CHANGE

E-MAIL INVOICES & STATEMENT____________________________________________

                                                                             (E-mail address)

LIST ALL AUTHORIZED USERS.  ALL OTHERS WILL BE DELETED:

(Attach additional sheet with printed name and signature if needed.)

1.___________________________       5. ___________________________

2.___________________________       6. ___________________________

3.___________________________       7. ___________________________

4.___________________________       8. ___________________________

CURRENT ADDRESS:

Street: _______________________________________________________

City ______________________________________ST ____Zip _________

P.O. Box: _____________________________________________________

City ______________________________________ST ____Zip__________

Phone #: (____) ___________________Fax #: (_____) _________________

Cell #: (_____) ___________________

AUTHORIZED SIGNATURE FOR CHANGES:

Printed Name: __________________________________________________

Signature: _______________________________ Date: _________________