Tex-an PIC Conversion Template

CUSTOMER NAME:
AGENCY/DIVISION NAME:

DIR TO PROVIDE Customer to Provide

Agency Code Divison Last Name First and Middle Name (Init) Billing TN Working TN ** Authorization Internation Service Address City, State Zip Code
Code (ALL CAPS) (Proper Case) code prompt? Call Blocking?
Yes or No Yes or No

3 3 15 maximum 15 maximum 10 digits 10 digits

Alpha Numeric & Numeric Numeric Only Alpha Only (ALL CAPS) Alpha Only (ALL CAPS) Numeric Only Numeric Only
313 123 JANE PATRICK 5124633000 5124633579 1701 SAN JACINTO AUSTIN, TX 78701

1 4/20/2011 8:29 AM
Tex-an PIC Conversion Template

2 4/20/2011 8:29 AM