EG America Enrollment Form
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
*
First Name
*
Last Name
*
Title
*
Phone
*
Email
*
Street (Physical Address Preferred)
*
City
*
State/Province (Abbreviation)
*
Postal Code
*
Payment Remittance Email
*
Supplier ID
Tax ID
If other buyers wish to pay you this way in the future, will your company accept their virtual credit card payments without fees or restrictions?
--select an item--
No
Yes
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
*
Owner Name
*
Owner Home Address
*
Owner City
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Owner State
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Owner Zip Code
*
Owner/Officer SSN
*
Date of Birth
ABA Routing Number
*
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!