Contact Information

Tell us who we should contact to follow up on your inquiry

First Name*

Last Name*

Email Address*

Phone*

Alternate Phone

Time Zone*

Best Time to Contact*

Practice Information

Tell us a little bit about yourself and your practice

Practice Name*

Practice Website

Address 1*

Address 2

City*

State*

Zip*

Legal Information

Tell us how your practice was established

Legal Name*

Federal Tax Id*

Business Start Date*

Legal Entity Type*

Address 1*

Address 2

City*

State*

Zip*

Processing Information

Tell us a little bit about how you accept payments

Do you currently accept credit cards?*

Yes

How many physical locations do you have?*

How do you accept payments? (Check all that apply)

Face to Face, In-Office

Manually, Key Entered

Through My Website

Monthly Volume?* ?

Average Transaction Size?* ?

Maximum Transaction Amount?* ?

Applicants

Information about the primary owners of the practice. PLEASE NOTE: Information must be provided for all principals owning more than 20% of the practice.

First Name*

Last Name*

Title*

Ownership %*

Home Phone*

Email*

Date of Birth*

Social Security Number*

Address 1*

Address 2

City*

State*

Zip*

Notes

Thoughts, questions, or concerns? Just let us know.

SphereCommerce LLC values your privacy and safeguards your personal information in compliance with applicable laws and regulations. We do not share your identification documents with third parties, except as required by law or regulatory authorities or for relevant business purposes.

For more details about our privacy policy, please visit our website

Let’s Get Started!

Contact Information

Practice Information

Legal Information

Processing Information

Applicants

Applicant 1

Notes