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[]
["Information in sections highlighted should be provided by:",null,null,null,null,"Service Add Form",null,null,null,null,null,null,null,"For Stericycle Internal Use Only"]
["Stericycle",null,null,null,null,null,null,null,null,null,null,null,null,"Case Number:"]
["Customer",null,null,null,null,"The parties agree that the following location(s) shall be added to the agreement between ACCT NAME and Stericycle dated CONTRACT DATE.",null,null,null,null,null,null,null,"Sold To Acct:"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"Ship To Acct:"]
["Site Information:",null,null,null,null,null,null,null,null,null,null,null,null,"Affiliation Code:","UAB"]
["Requested Start Date: ",null,null,null,null,null,null,null,null,null,null,null,null,"Hospital Account Only"]
["Site  Name: ","Ex. PI Name Building Abbreviation Room #",null,null,null,"Services Requested:"]
["Service Address: ",null,null,null,null,null,null,"Regulated Medical Waste Service"]
["Floor/ Ste #",null,null,null,null,null,null,null,null,null,null,null,null,"Service Frequency:","Select One"]
["Service City, State, Zip: ",null,null,null,null,null,"Generator ID:",null,null,null,null,null,null,"Material:","20001062 RMW INCIN SUB"]
["Site Phone: ",null,null,null,null,"REQUIRED for RMW (DE, ME, NJ, RI, SC, PR) BIC REQUIRED FOR NYC. EXEMPTION for South Carolina: If the generator is a veterinarian or a tattoo parlor / artist, no RMW generator ID number is required.",null,null,null,null,null,null,null,"Steri-Safe Material:","Select One"]
["Site Primary Contact: ",null,null,null,null,null,null,null,null,null,null,null,null,"# of Stops:"]
["Contact Email: ",null,null,null,null,null,null,null,null,null,null,null,null,"# of Containers:"]
[]
["Hours of Operation",null,null,null,null,null,null,"Trace Chemotherapy Waste Service"]
["Monday","8-5 pm",null,null,null,null,"# of Stops:",null,null,null,null,null,null,"Service Frequency:","Select One"]
["Tuesday","8-5 pm",null,null,null,null,"# of Containers:",null,null,null,null,null,null,"Material:","Select One"]
["Wednesday","8-5 pm"]
["Thursday","8-5 pm",null,null,null,null,null,"Pathological Waste Service"]
["Friday","8-5 pm",null,null,null,null,"# of Stops:",null,null,null,null,null,null,"Service Frequency:","Select One"]
["Saturday",null,null,null,null,null,"# of Containers:",null,null,null,null,null,null,"Material:","Select One"]
["Sunday"]
[" Pickup frequency / # of containers needed:","Ex. Weekly pickups, 2 TB01 containers",null,null,null,null,null,"Rx/Rx Affiliate/Hazardous "]
[null,null,null,null,null,"must provide to be serviced EPA ID:",null,null,null,null,null,null,null,"Legacy Acct#"]
[null,null,null,null,null,null,null,null,"Rx Material:",null,"Select One",null,null,"Rx Service Frequency:","On Call"]
[null,null,null,null,null,null,null,null,"Haz Material:",null,"Select One",null,null,"Haz Service Frequency:","On Call"]
[null,null,null,null,null,null,null,null,"Rx Affl Material:",null,"Select One",null,null,"Compatible Containers:"]
[null,null,null,null,null,null,null,"Rx Affl Annual Stops:",null,null,null,null,null,"Incompatible Containers:"]
[null,null,null,null,null,null,null,"Rx Affl Annual Cnt Count:",null,null,null,null,null,"P-Listed Container:"]
[]
["Billing Information",null,null,null,null,null,null,"Non-Haz Pharm",null,null,null,null,null,"Annual Stops:"]
[null,null,null,null,null,"must provide to be serviced Gen ID:",null,null,null,null,null,null,null,"Annual Container Count:"]
[null,null,null,null,null,"Accts in FL, IL, IN, MI, MN, RI, WA & WI must have HDDS\nor RxAffl Program (Hosp Accts)",null,null,null,null,null,null,null,"Service Frequency:","Select One"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"Material:","Select One"]
["Billing Name:","UAB Campus: 3001087345"]
["Billing Address:","1800 9th Avenue South",null,null,null,null,null,"HDDS (not applicable to Hospital Accounts)",null,null,null,null,null,"Checklist Needed:"]
["Billing City, State, Zip:","Birmingham, AL 35294",null,null,null,null,null,null,null,null,null,null,null,"Legacy Acct#"]
[null,null,null,null,null,"must provide to be serviced EPA ID:",null,null,null,null,null,null,null,"Service Frequency:","Select One"]
[null,null,null,null,null,"If Multi-sites are being added customer must fill out the following:",null,null,null,null,null,null,null,"# of Stops:","Select One"]
["Grant Account/ GL #:",null,null,null,null,"Hazardous Waste Generator Status:",null,null,null,null,"Must Select One",null,null,"Containers per Year:"]
[null,null,null,null,null,"Opted into Subpart P?",null,null,null,null,"Must Select One",null,null,"Compatible Containers:"]
[null,null,null,null,null,"License to Prescribe",null,"Board of Pharmacy#:",null,null,null,null,null,"Incompatible Containers:"]
[null,null,null,null,null,null,null,"Expiration:",null,null,null,null,null,"P-Listed Container:"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"Hosp Acct Only:"]
[]
["If yes, please provide a copy of the Exemption Certificate.",null,null,null,null,null,null,"CsRx",null,null,null,null,null,"Legacy Acct#"]
[null,null,null,null,null,"must provide to be serviced EPA ID:"]
["Special Billing Requirements:",null,null,null,null,null,null,null,"Checklist Needed:",null,null,null,null,"Material:","Select One"]
[null,null,null,null,null,null,null,null,"Service Frequency:",null,"Select One",null,null,"Container Details: ","                      Quantity:"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"                      Quantity:"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"                      Quantity:"]
[]
[null,null,null,null,null,null,null,"Sharp Services"]
["The added location(s) shall be serviced according to the terms and conditions under the agreement beween the parties. By signing below, I acknowledge that I am Customer’s authorized officer or agent and that I have the authority to bind Customer to this Additional Site Form. All other terms and conditions of the agreement between the parties not modified herein shall remain in full force and effect.\n\n",null,null,null,null,"(required if RMW is not being added at the same time) MWG ID: "]
[null,null,null,null,null,null,null,null,"Service Frequency:",null,"Select One",null,null,"SMS Material:","Select One"]
[null,null,null,null,null,null,null,null,"Service Frequency:",null,"Select One",null,null,"KRB Material:","Select One"]
[null,null,null,null,null,null,null,null,"Service Frequency:",null,"Select One",null,null,"RxB Material:","Select One"]
[]
[]
["Customer Name:",null,null,null,null,null,null,"Shredding Services",null,null,null,null,null,"Only fill out if Off-Site or On-Site is filled out"]
["Signature:",null,null,null,null,null,null,null,null,null,null,null,null,"Container Type:"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"# of Containers:"]
["Date:",null,null,null,null,null,null,null,"Material: ",null,"Select One",null,null,"Service Frequency:","Select One"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"# of Stops:"]
["Stericycle Rep:",null,null,null,null,null,null,null,"Material: ",null,"Select One",null,null,"Service Frequency:","Select One"]
["Signature:",null,null,null,null,null,null,null,null,null,null,null,null,"# of Stops:"]
[null,null,null,null,null,null,null,null,"Purge Off-SIte: ",null,"Select One"]
["Date:",null,null,null,null,null,null,null,"Sub Purge Off-SIte: ",null,"Select One"]
[null,null,null,null,null,null,null,null,"Purge On-Site:",null,"Select One",null,null,"Service Frequency:","Select One"]
[null,null,null,null,null,null,null,null,"Sub Purge On-Site",null,"Select One",null,null,"Requested Purge Date:"]