Prudential Cleanroom CV Representative Action Questionnaire

Prudential Cleanroom CV Representative Action

Date*
YYYY dash MM dash DD
Company*
Prudential Representative*
Service Agreement Signature Responsibility
SRA/PO Expiration date
MM slash DD slash YYYY
Date of last CV
MM slash DD slash YYYY
Program Type
- Rental
- COG
- Both
Additional Products / Services / Locations
Additional products or services we can provide service for? (please list)
Is customer currently using Prudential Industrial Services?
- yes
- no
Current Provider
List of other locations to offer services. Include DBA, Phone, Address, Contact and Need (Industrial, Cleanroom, National, Direct Sale)
Is Customers A/R status current? Action Taken to resolve? If current thank customer.
A/R
A/R Initial
- Check this box to initial this has been completed
A/R Date Corrected
MM slash DD slash YYYY
Sales & Service action needed
S&S Action
S&S Initial
- Check this box to initial this has been completed
S&S Date Corrected
MM slash DD slash YYYY
Production Department action needed
PD Action
PD Initial
- Check this box to initial this has been completed
PD Date Corrected
MM slash DD slash YYYY
DAY*
PLANT*
ROUTE*
Please enter a number less than or equal to 999.
ACCOUNT #*
Please enter a number less than or equal to 999.
WEEKLY VOLUME*
Please enter a number greater than or equal to 1.
CUSTOMER #*
Please enter a number greater than or equal to 1.
Signature for desktop users without touchscreen
- Check the box to sign without actual signature (for desktop users without touchscreen)
Prudential Signature*
For Admin Use:
SLX ID
REPORT_REQUESTID
Name
This field is for validation purposes and should be left unchanged.

Form 10118web, Rev. 08/14/18

Prudential Cleanroom CV Representative Action

Additional Products / Services / Locations

Is Customers A/R status current? Action Taken to resolve? If current thank customer.

Sales & Service action needed

Production Department action needed

For Admin Use: