Merchant Referral Form |

Check, ACH, Gift & Loyalty

Thank you for the Merchant Referral! We will contact the Merchant Referral on your behalf within 2 business days. We will price the Merchant Referral according to your previously provided referral pricing schedule. If you haven't provided us a schedule, we will use our descretion to price the Merchant Referral at a competitive rate. Thank you again for the referral! Please fill out the following form and click the Submit button at the bottom of the page.

Merchant DBA Name:
Point of Contact:
Phone #:
Merchant Email:
Existing Processing Equipment:
Type of Business:
Address:

Desired Program(s):

Check/ACH Services

Gift/Loyalty Services

Addtional Notes/Comments:

Merchant Service Provider:		Paya ISO ID#:
Referring Agent:
Agent's email address:

Phone Number:

City:

State:

-Select One- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other