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

No

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.

Let’s Get Started!

Contact Information

Practice Information

Legal Information

Processing Information

Applicants

Applicant 1

Notes