General Information

Client's Business Name*

Client's Corporate / Legal Name*

Business Location

Location Address

Address*

City*

State*

Zip*

Corporate Location

Corporate Address

Address*

City*

State*

Zip*

Contact Information

Location Phone*

Location FAX*

Contact Name*

Contact Phone*

Customer Service Phone*

Contact Email*

Business Structure

Business Type*

Federal Tax ID*

Tax Type*

Prior Security Breach?*

Tax Filing Name*

Business Website Address*

Business Email*

D&B# (Optional)

Multiple Locations?*

If yes, enter # of locations*

Date Business Started*

Length of Current Ownership*

Send Retrieval / Chargeback Requests to:*

State Filing*

NOTE: Failure to provide accurate information may result in a withholding of merchant funding per: IRS regulations.

Owners/Partners/Officers

OWNER/PARTNER/OFFICER 1

Name*

Title*

% of Ownership*

Guarantor*

Address*

City*

State*

Zip*

Phone*

Social Security #*

Date of Birth*

Email*

Add Additional Owners

OWNER/PARTNER/OFFICER 2

Name*

Title*

% of Ownership*

Guarantor*

Address*

City*

State*

Zip*

Phone*

Social Security #*

Date of Birth*

Email*

OWNER/PARTNER/OFFICER 3

Name*

Title*

% of Ownership*

Guarantor*

Address*

City*

State*

Zip*

Phone*

Social Security #*

Date of Birth*

Email*

OWNER/PARTNER/OFFICER 4

Name*

Title*

% of Ownership*

Guarantor*

Address*

City*

State*

Zip*

Phone*

Social Security #*

Date of Birth*

Email*

Bank Account Information

Bank Name*

Bank Phone*

Routing Number*

Account Number*

ACH Method*

Referral (optional)

Referral Business Name

Business Address

City

State

Zip

Contact

Phone

855.468.7876

7900 Glades Rd, Suite 340

General Information

Business Location

Corporate Location

Contact Information

Business Structure

Owners/Partners/Officers

Bank Account Information

Referral (optional)

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855.468.7876

7900 Glades Rd, Suite 340

General Information

Business Location

Corporate Location

Contact Information

Business Structure

Owners/Partners/Officers

Bank Account Information

Referral (optional)

Call us

Latest News

Are You Dental Patients Protected Online?

Is Your Medical Practice HIPAA-Compliant?

What Is On the Patient-Payment Horizon?

Quick Links

Sign up for Our Newsletter