ASC X12 Code Maintenance Request


	ASC X12 CODE MAINTENANCE REQUEST A. Submitter Information B. Reference Used C. Intended Use D. Reason For Change E. Proposed Work

*** The CMR tool is only used for a simple code addition. The proposed code can point to an existing Code Source. However, if a new Code Source needs to be created, submit a regular Work Request Form. ***


	A. Submitter Information

	First Name:

	Last Name:

	Title:

	Company:

	Address 1:

	Address 2:

	City:

	State/Province:

	Country:

	Postal Code:

	Phone:

	Fax:

	Email:

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