3rd-party-bill-setup

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A wholly owned subsidiary of MBS Textbook Exchange, Inc. Third Party Billing Setup
TODAY'S DATE
SCHOOL NAME
NOTE: When third party billing is going to be used, you must complete the following form and return it to MBS Direct.
COMPANY CONTACT NAME EMAIL
PHYSICAL ADDRESS CITY STATE ZIP
PHONE FAX
ACCOUNTING CONTACT:ACCOUNTING CONTACT:
NAME EMAIL
TITLE
PHONE FAX
STATEMENT ADDRESS:
COMPANY CONTACT NAME EMAIL
ATTENTION
ADDRESS CITY STATE ZIP
MBS DIRECT • 2711 WEST ASH, COLUMBIA, MO 65203 • PHONE 800-325-3252 • FAX 800-325-5152MBS DIRECT • 2711 WEST ASH, COLUMBIA, MO 65203 • PHONE 800-325-3252 • FAX 800-325-5152
	TODAYS DATE: 
	SCHOOL NAME: Johns Hopkins University - EP
	COMPANY CONTACT NAME: 
	EMAIL: 
	PHYSICAL ADDRESS: 
	CITY: 
	STATE: 
	ZIP: 
	PHONE: 
	FAX: 
	NAME: 
	EMAIL_2: 
	TITLE: 
	PHONE_2: 
	FAX_2: 
	COMPANY CONTACT NAME_2: 
	EMAIL_3: 
	ATTENTION: 
	ADDRESS: 
	CITY_2: 
	STATE_2: 
	ZIP_2: