Referral Agent Application Form

This application is intended to be completed in its entirety to ensure timely processing and setup of your Electronic Payment Processing Services account. It is our goal to make this application process as simple as possible while, at the same time, ensuring we have the information necessary to meet industry requirements. We hope you'll find this application easy-to-use and the requirements reasonable.

HOW TO SUBMIT THIS APPLICATION - Simply fill out all required fields and submit form.

Note: Fax images of photo IDs are usually illegible. A scanned image is preferred.

Hold ctrl when selecting multiple files for uploading in each section.

IMPORTANT - This application must be complete and include all additional documents before we can process it.

Agent Information