BioCare DSCSA Onboarding – Beginadmin2023-04-27T13:39:00-07:00 Please complete the following information. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Customer Business ContactsProvide your business contact(s) for DSCSA Serialization.LayoutBusiness Contact First Name *Business Contact Last Name *LayoutBusiness Contact Title *Business Contact Phone Number *Business Contact Email * + Add Another Business Contact - Remove This ContactCustomer Technical ContactsProvide your technical contact(s) for DSCSA Serialization.LayoutTechnical Contact First Name *Technical Contact Last Name *LayoutTechnical Contact Title *Technical Contact Phone Number *Technical Contact Email * + Add Another Technical Contact - Remove This Technical ContactCustomer Global Location Number (GLN)Check with your GPO to determine if they’ve purchased a GLN on your behalf. If not, you can obtain your GLN here.Location Name * Location Name GLN * GLN GS1 Company Prefix * GS1 Company Prefix Address * Address Address Line 1Address Line 2City--- Select State ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeType * Type --- Select Type ---Sold ToShip ToOtherOther Specified * + Add Another Location - Remove This LocationThird Party Integrator (Track & Trace) *Please identify your L5 Service Provider (SP) from the entries below. If you would like to use a Portal to access your DSCSA EPCIS data from SAP ICH, please check the ‘SAP ICH Portal Customer’ Box. If your L5 SP is not listed below, please specify this under ‘Other’, identify the SP and fill out the technical contact and email address.AxwayFrequentzLSPediarfxcelSAP ICHSAP ICH Portal CustomerTraceLinkOtherOther Communication Method Technical Contact If “Other” is selected, provide technical contact and email address LayoutOther SP Technical Contact First Name *Other SP Technical Contact Last Name *Other Communication Method Technical Contact Email *Submit
