Referrer First & Last Name

Referrer Email Address

Submitter First & Last Name

Submitter Email Address

Merchant's Business Name(DBA)

Merchant First Name

Merchant Last Name

Merchant Business Address

Merchant City

Merchant State Please select a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia 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

Merchant Zip

Merchant Email Address

Merchant Phone

Phone Type Please select phone type Home Mobile Work

I agree to receive text messages from Deluxe

Best Time to Call Merchant

Merchant's Current Payment Provider

Merchant's Preferred Language

Have merchant statements to upload? Please select yes or no Yes No

Does merchant know Deluxe will be calling? Please select yes or no Yes No

Does merchant have an active account with you? Please select yes or no Yes No

Please choose a branch Please select a branch FIRST SECURITY BANK OK

Additional Comments from Referrer

Upload up to 5 statements, as pdf, word, jpeg or png files. Maximum file size 4MB. If you need to send a larger file, please email the file directly to FIsales@deluxe.com

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Unsupported file type selected. Please select valid file type. Eg: .pdf, .jpg, .jpeg, .png, .doc, .docx