Address Phone Change Request.pdf - OfficeMate Software Solutions

Address/Phone Number Change Request
An address or phone number change request is granted exclusively for the purpose of moving your office to a new
address, changing area codes, or changing a business name (not an ownership change).
Eyefinity has granted you a non-exclusive, non-transferable license to use one copy of OfficeMate or ExamWRITER on
one computer workstation or one computer server network with the purpose of distributing it to other client computers
attached to the network server at a single location. An address or phone number change request will not be granted for
the purpose of using OfficeMate or ExamWRITER at two or more locations. To use OfficeMate or ExamWRITER at
additional locations, you must purchase additional licenses and support.
To change your address, phone number, or business name, complete the information below, ensuring that all of the
information you record is correct, and fax it to Eyefinity at 866.202.6324. If you have any questions about this form or
process, call 1.800.269.3666 or send an e-mail to clientmanagers@eyefinity.com. Please note that we cannot process
your request without the completed name, signature, and date information on page 2.
Request Type
Address Change Business Name Change Area Code/Phone Number Change
Old Information
Locate your version number in OfficeMate/ExamWRITER in the blue title bar at the top of the main window.
OfficeMate/ExamWRITER Version Number
To view your current address and phone number information in your program, click Setup (in OfficeMate) or Tools (in
ExamWRITER) and select Business Names.
Business Name
Phone Number
New Information
• The information in the fields marked with an asterisk (*) will appear exactly as you write it in Box 33 on your CMS
forms.
• The information in the Name 1 and Name 2 fields will appear exactly as you write it on your Statements and Receipts.
*Name 1 (maximum of 40 characters)
Name 2 (maximum of 40 characters)
*Practice Address Line 1 (maximum of 30 characters)
*Practice Address Line 2 (maximum of 30 characters)
Address/Phone Number Change Request (1112) Page 1 of 2

New Information, cont.
*City *State *Zip Code + 4
*Practice Telephone Number
Fax Number
Email Address (Gmail addresses are not recommended, because Gmail blocks certain support files that we may need to
send to you. Your email address is required receive software upgrades, newsletters, promotions, offers, and other
communications.)
Additional Processing Information
In case we have questions about your address/phone number change request while we are processing it, please
complete the following fields:
Name of the Person Submitting this Request
Phone Number of the Person Submitting this Request
Acknowledgement
I certify that I am requesting this change in order to modify my phone number, address, or business name. I understand
that it is unlawful to use one OfficeMate Suite software license on more than one computer workstation or computer
server network. Eyefinity requires an annual fee for all support and upgrades.
Licensed Software Owner’s Name (Print)
Licensed Software Owner’s Signature
Date
Activation Program Delivery Method
Please choose your desired delivery method below:
Mail Activation CD-ROM
Email Activation Program
Note: Mailed activation CD-ROMs will be sent within 5 to 7 business days after we receive and approve this request. E-
mail activation programs will be e-mailed within 1 to 3 business days after we receive and approve this request. If you are
expecting to receive the activation program via e-mail, ensure that your inbox is not configured to send e-mail messages
received from officemate.net to your junk mail folder. *If you receive e-mail through a Gmail account, your account will
automatically block our e-mail message. If you are expecting to receive the activation program via e-mail and you have
not received it within 1 to 3 days business days after we receive and approve this request, call us at 1.800.269.3666.
Address/Phone Number Change Request (1112) Page 2 of 2