CHRIMS, INC. - Code Request E-Mail Form

Code Request E-Mail Form

To automate the assignment of new codes, CHRIMS has deployed this e-mail ready code request form. This will help improve the process for requesting and receiving new codes. Please e-mail any questions or concerns to settlement@chrims.com, we are always interested in hearing your thoughts.

Please fill out the necessary fields in order to receive a quick response. You will be notified within 48 hours with a reply.

(*) Denotes required fields.


Code Type
Requestor
* First Name
* Last Name
* E-Mail Address
* Phone Number
Company Category
Company Name
Customer Information
* Name
Secondary Name
* Address
* City
* State/Province
Postal/Zip Code
* Country
* Date Needed	Format: mm/dd/yyyy
Desired Code
* If you know the code you would like to request please enter above

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