Quick Application

(636) 220-7255 info@ReliantPay.com

■ eCommerce

■ EMV Chip & Pin Security

■ Retail Merchants

■ Websites

■ B2B Merchant Services

Evening Phone:

Quick Application

Contact Information: Daytime Phone:

DBA Name:

Average Ticket:

Processing Information: Processing Type:

Other Information: Comments:

State:

Please complete the following information. We only review applications for companies with a valid business that want to accept credit cards for legitimate business transactions. This application and any discounts on equipment purchases is subject to account approval. A separate signed application will also be required.

(877) 397-3127

Annual Processing Volume:

Business Description:

Applicant Information: First Name:

How Do/Will you Process Transactions:

City:

I authorize ReliantPay to verify my business and credit history. I understand this application is subject to the review and acceptance by ReliantPay.

Business Information: Year Business Started:

Address:

Zip Code:

Last Name:

Email:

Business Information: Legal Name:

High Ticket:

ReliantPay is a registered Independent Sales Organization of Wells Fargo Bank, N.A., Concord, CA

American Express requires separate approval.

The Clover name and logo are owned by Clover Network, Inc. a wholly owned subsidiary of First Data corporation, and are registered or used in the U.S. and many foreign countries.

14280 Manchester Rd. ~ St. Louis, MO 63011
(636) 220-7255

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ReliantPay, Inc.