Citizens Bank Enrollment
How would you like your virtual card processed?
*
--select an item--
I will process the payment.
I would like Priority to process my payments.
Enrollment Form
Company
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First Name
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Last Name
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Title
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Phone
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Email
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Street (Physical Address Preferred)
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ATTN CLIENT CARE 750 CANYON DR STE 450
City
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State/Province
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Postal Code
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Payment Remittance Email
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Supplier ID
Site ID
Please confirm Site ID
*
--select an item--
Yes
No
Tax ID
Quick Start Application
Add'l Data Requirements for Priority Processing Option
Legal Entity
*
--select an item--
501C-3
C Corporation
LLC
Partnership
S Corporation
Sole Proprietor
Business Description
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Owner Name
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Owner Home Address
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ATTN CLIENT CARE 750 CANYON DR STE 450
Owner City
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COPPELL
Owner State
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TX
Owner Zip Code
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75019
Owner/Officer SSN
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Date of Birth
ABA Routing Number
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ABA Account Number
*
*NOTE: The fees below are not in addition to your current merchant processing fees.
I accept the following pricing from Priority Payment Systems: 1.50% - 2.60%
*
--select an item--
Yes
No
I accept the Merchant Services Program Guide
*
--select an item--
Yes
No
clear
Typed
Drawn
I agree to terms and services.
Email
Signature
*
Date
*
Signature
*
Date
*
Thank you for your submission!