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In order to be able to resume this form later, please enter your email and choose a password.
Your Email:
A Password:
Confirm Password:
Password must contain the following:
12 Characters
1 Uppercase letter
1 Lowercase letter
1 Number
1 Special character
BUSINESS INFORMATION
All fields with an * asterisk are required and must be completed to submit the application.
Company Legal Name
Name company is registered with the state
DBA Name (Doing Business As)
Business Name on the building
Business Phone
ex: 111-111-1111
Business Fax
ex: 111-111-1111
Business Email
Ex: myemail@InComm.com
Mobile Phone number is required to receive a one-time password once the Terminal or Web Access is received.
Mobile Phone
ex: 111-111-1111
Total percentage of State and Local Sales Tax (Ex 8 %)
This is used to configure terminal for transaction purposes.
TERMINAL DEVICE OPTIONS (SELECT ONE)
Equipment selection is Required
N82 (
This terminal is portable and will have to connect to Wi-Fi. The scanner is built into the terminal.)
Wired Network Connection
(This terminal will have both Wi-Fi and an ethernet port for a wired connection and includes a USB laser barcode scanner. This terminal must be plugged into a power source to operate.)
Web Application ONLY
(NO equipment provided by InComm) (Merchants who use equipment that allows them to access a web browser are not required to obtain InComm devices. Merchant will need to provide their own USB Swipe Magnetic Card Reader and USB Scanner for scanning items.) Your business will not receive a terminal device if Web Application is selected.
Check "Yes" if more than one terminal is needed
Yes
BUSINESS ADDRESS INFORMATION
Address 1
ex: 123 SW Main Street
Address 2
ex: Suite, Building
City
State
Zip Code
Do you have multiple locations?
Yes
No
How many locations do you have?
Is the Billing Address different from the Company Address?
Yes
No
BUSINESS BILLING INFORMATION
Billing Address Line 1
ex: 123 SW Main Street
Billing Address Line 2
ex: Suite, Building
Billing City
Billing State
Billing Zip Code
Billing Phone Number
ex: 111-11-1111
PRINCIPAL INFORMATION
Note: All Principal information is required and should include the business owner's personal information only
Principal First Name
Principal Last Name
Principal Email
Ex: myemail@InComm.com
Principal Phone
ex: 111-111-1111
Business Owner Title
Please select...
President
Vice President
Treasurer
Chief Financial Officer
Other
If "Other" Title is selected. Enter other title here
Home Address 1
(Home Address is REQUIRED as part of the background check on the Principal applying.)
ex: 123 SW Main Street
Home Address 2
ex: Suite; Building
City
State
Zip Code
COMPANY INFORMATION
Company Type
Please select...
Sole Proprietor
C-Corporation
S-Corporation
Limited Liability Company
Limited Liability Partnership
Partnership
Other
Limited Liability Type
C = C corporation
S = S corporation
P = partnership
If "Other" is selected, enter other company type here
STATE ID/ TAX BUSINESS REGISTRATION INFORMATION
Type of Business
Please select...
Pharmacy
Grocery
Both
Federal ID/EID
NPI Number
Dun & Bradstreet #
If applicable
SIC
If applicable
Number of year(s) in business
What percentage % of your inventory is Domestic? (UPC11)
What percentage % of your inventory is International? (EAN - GTIN)
PROGRAM INTEREST
Which Program are you interested in?
Please select...
OTC Network Only
Prepaid & OTC Network
ADDITIONAL INFORMATION
Display Designation (choose one):
Please select...
72 count pole display
18 count counter display
Both 72 and 18
Vanilla Service Option:
I would like to offer the
Vanilla® Visa
products
Yes
No
I would like to offer the
Vanilla® Reload Network
Yes
No
How did you hear about us?
Please select...
Word of Mouth
Health Plan
Broker
Tradeshow or conference
Google Search
Other
If "Other" is selected, how else did you hear of us?
Sales Rep
Please select...
YAG REP 1
YAG REP 2
YAG REP 3
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