Cleveland Clinic Health System  
 

 

Cleveland Clinic Health System
Subscription Requisition Form
 

   - indicates required field

 

    Date:               Hospital Name:       Emp # or Code:
 

Contact Information:

Name:  Email:       Phone # : 
     
Department Name:
Department Requesting Code:
     

If necessary:

 Association Name:
   Association Member Number:
  Association Member Name:

Accounting Information

General Ledger Coding   Activity Management Coding
     
C ompany Oracle Accounting Unit
(e.g. 1234-1234-12345) 		Account
(6 digits) 		  Education/Project/Grant No
 (12 digits) 		Account Category
 (5 digits) 		Percentage
1000   %
1000   %
1000   %

Subscription Ordering Information

Direct questions to Matthews Subscription Service at 800-673-3705, e-mail: [email protected]

  Name Dept Mail Code
Mail To:
Complete Address :





 
Subscription Title:
Publisher: Publisher Phone: Quantity:
ISSN #:  Unit Price:

Please select:

   
Comments:

Subscription Title:
Publisher: Publisher Phone: Quantity:
ISSN #:  Unit Price:

Please select:

   
Comments:

Subscription Title:
Publisher: Publisher Phone: Quantity:
ISSN #:  Unit Price:

Please select:

   
Comments:

Subscription Title:
Publisher: Publisher Phone: Quantity:
ISSN #:  Unit Price:

Please select:

   
Comments:

Subscription Title:
Publisher: Publisher Phone: Quantity:
ISSN #:  Unit Price:

Please select:

   
Comments:

Please remember to fax all Member forms, renewal notices, advertisements, publisher invoices or any other supporting documentation to Matthews Subscription Service upon completion of this order form.  Please refer to your Order Confirmation Number in your fax.  Your Order Confirmation Number will be displayed after you Submit this form.  Fax: 800-421-8816
 

Please check this box if you will be faxing supporting documents.

        

Thank You for your order!

All orders are processed through the Matthews Subscription Service.  Matthews is acting as an agent on the behalf of the Cleveland Clinic Health System.