X12 Representatives

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Member Organization Name or Individual Member Name
 
Member
 
Primary Representative
 
Primary Representative's Name
Primary Representative's Title
Primary Representative's Address1
Primary Representative's Address2
Primary Representative's City
Primary Representative's State
Primary Representative's ZIP
Primary Representative's Phone
Primary Representative's Email
 
Alternate Representative
 
Alternate Representative's Name
Alternate Representative's Ttile
Alternate Representative's Address1
Alternate Representative's Address2
Alternate Representative's City
Alternate Representative's State
Alternate Representative's ZIP
Alternate Representative's Email
Alternate Representative's Phone
 
Alternate Representative 2
 
Alternate 2 Representative's Name
Alternate 2 Representative's Title
Alternate 2 Representative's Address1
Alternate 2 Representative's Address2
Alternate 2 Representative's City
Alternate 2 Representative's State
Alternate 2 Representative's ZIP
Alternate 2 Representative's Phone
Alternate 2 Representative's Email
 
Billing Representative
 
Billing Representative's Name
Billing Representative's Title
Billing Representative's Address1
Billing Representative's Address2
Billing Representative's City
Billing Representative's State
Billing Representative's ZIP
Billing Representative's Phone
Billing Representative's Email
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