HFD - Merchant Enrollment Form

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Merchant Enrollment Form

BUSINESS INFORMATION

Entity Type(Required)

Medical / Healthcare Provider

Non-Medical Business

Legal Business / Practice Name(Required)

Doing Business As / Brand Name(Required)

Legal Entity Type (LLC, S-Corp, C-Corp, Partnership, etc.)(Required)

State Formed(Required)

Tax ID or EIN Number(Required)

National Provider Identifier (NPI)(Required)

Use your practice's organizational (Type 2) NPI if you have one

Website(Required)

CONTACT INFORMATION

Office Manager / Decision Maker(Required)

(decision maker for refunds, cancellations, etc)

Office Manager / Decision Maker Email(Required)

Office Manager / Decision Maker Phone(Required)

Dispute Resolution Contact(Required)

(for disputes/chargebacks)

Dispute Resolution Contact Email(Required)

Dispute Resolution Contact Phone(Required)

PRINCIPAL INFORMATION

Name of Principal Owner(Required)

Title(Required)

Principal Owner Email(Required)

Principal Owner Phone(Required)

LOCATION

I am enrolling for:

One location

Multiple locations

Address(Required)

Street Address City State ZIP Code

BANKING INFORMATION

Bank Name:(Required)

(Should match voided check or bank letter)

Routing Number:

(Should match voided check or bank letter)

Official Business Name on Bank Account:(Required)

(Should match voided check or bank letter)

Account Number:

(Should match the voided check or bank letter)

SIGNATURE

Authorized Signer First & Last Name:(Required)

Authorized Signer Position:(Required)

Date(Required)

MM slash DD slash YYYY

Email(Required)

Signature(Required)

*A copy of each Principal Owner's valid, government-issued photo ID must be attached to this application(Required)

Max. file size: 25 MB.

*Click to attach copy of valid principal ID

*A voided check or bank letter must be attached to verify your funding account information(Required)

Max. file size: 25 MB.

*Click to attach voided check or bank letter. Must match the banking information provided on this form

*Medical / Healthcare Providers Only: A copy of your current, valid medical or professional license must be attached to this application(Required)

Max. file size: 25 MB.

*Click to attach copy of current, valid medical license

Name(Required)

(as shown on your income tax return). Name is required on this line; do not leave this line blank.

Business name/disregarded entity name, if different from above(Required)

Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes.(Required)

Individual/sole proprietor

C Corporation

S Corporation

Partnership

Trust/estate

Limited Liability Company

Others

If Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)

Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner.

Exemptions (codes apply only to certain entities, not individuals):

Exempt payee code (if any)

Exemption from FATCA reporting code (if any)

(Applies to accounts maintained outside the U.S.)

Address (number, street, and apt. or suite no.) See instructions.

City, state, and ZIP code

Requester’s name and address (optional)

List account number(s) here (optional)

Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.

Social Security Number

or Employer identification number

Certification

Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.

Signature of U.S. person(Required)

Date(Required)

MM slash DD slash YYYY

General Instructions

Section references are to the Internal Revenue Code unless otherwise noted.
Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9.

Purpose of Form

An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following.

Form 1099-INT (interest earned or paid)
Form 1099-DIV (dividends, including those from stocks or mutual funds)
Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)
Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)
Form 1099-S (proceeds from real estate transactions)
Form 1099-K (merchant card and third party network transactions)
Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)
Form 1099-C (canceled debt)
Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later.

Merchant Enrollment Form

BUSINESS INFORMATION

CONTACT INFORMATION

PRINCIPAL INFORMATION

LOCATION

BANKING INFORMATION

SIGNATURE

Taxpayer Identification Number (TIN)

Certification

General Instructions

Purpose of Form

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Get Started Today!

Complete the form, we’ll make financing your customers the easiest part of your day!