EDI Profile Form

If you are interested in becoming an EDI Trading Partner, please fill out and submit the below EDI Application.

Company Information

Company Name

Street Address

Address Line 2

City State / Province / Region Postal / Zip Code

Phone Number - (###) - ### ####

Fax Number - (###) - ### ####

Email Address

Webpage

(http://www.yourcompany.com)

EDI Contacts

Contact #1 Name Responsibility - - Phone Number Email Address

Contact #2 Name Responsibility - - Phone Number Email Address

Contact #3 Name Responsibility - - Phone Number Email Address

Interchange (ISA) Qualifier/ID Production (ex. 01/003151735) Test (ex. 01/003151735)

Group (GS) ID Production (ex. 003151735) Test (ex. 003151735)

Name of Software/Translator

Do you use a third party network? Yes No

If so, who?

List your transmission times Send Receive

Send Receive

Time Zone

What do you use for Segment Terminator?

Decimal Hex

What do you use for Element Separator?

Decimal Hex

What do you use for Sub Elem. Separator?

Decimal Hex

Select Documents you currently use and/or plan to use.

	Current		Future
810 - Invoice	Send	Receive	Send	Receive
820 – Remittance Advice	Send	Receive	Send	Receive
824 – Application Advice	Send	Receive	Send	Receive
850 – Purchase Order	Send	Receive	Send	Receive
855 – PO Acknowledgement	Send	Receive	Send	Receive
856 – Ship Receivetice	Send	Receive	Send	Receive
864 – Text	Send	Receive	Send	Receive
997 – Functional Acknowledgement	Send	Receive	Send	Receive
210 – Motor Carrier Freight Invoice	Send	Receive	Send	Receive

What version of the X12 standard are you using? (ex. 004010)

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