D&H Distributing Enrollment Form
How would you like your virtual card processed?
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I will process the payment (SIP).
I would like Priority to process my payments (BIP).
Enrollment Form
Company
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First Name
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Last Name
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Title
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Email
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Street (Physical Address Preferred)
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City
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State/Province (Abbreviation)
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Postal Code
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Payment Remittance Email
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Tax ID
Our company accepts virtual card payments from all buyers, There are no fees or stipulations to this acceptance.
--select an item--
No
Yes
Quick Start Application
Add'l Data Requirements for Priority Processing Option
Legal Entity
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--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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Owner City
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Owner State
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Owner Zip Code
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Owner/Officer SSN
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Date of Birth
ABA Routing Number
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ABA Account Number
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*NOTE: The fees below are not in addition to your current merchant processing fees.
I accept the following pricing from Priority Payment Systems: 1.80- 2.58%. Fees will be taken at the time payments are processed.
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--select an item--
Yes
No
I accept the Merchant Services Program Guide
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--select an item--
Yes
No
clear
Typed
Drawn
I agree to terms and services.
Email
Signature
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Date
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Signature
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Date
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Thank you for your submission!