Pharmacy Partner Application

Please complete the following application that will be used to generate your contract.

If you need help completing this form, please contact our Sales and Support Team at 877-535-4707 EST during normal business hours for assistance.

BUSINESS INFORMATION
All fields with an * asterisk are required and must be completed to submit the application. 

Name company is registered with the state

Business Name on the building

ex: 111-111-1111

ex: 111-111-1111

Mobile Phone number is required to receive a one-time password once the Terminal or Web Access is received. 

ex: 111-111-1111

This is used to configure terminal for transaction purposes.
TERMINAL DEVICE OPTIONS (SELECT ONE) 


BUSINESS ADDRESS INFORMATION


ex: 123 SW Main Street

ex: Suite, Building




BUSINESS BILLING INFORMATION

ex: 123 SW Main Street

ex: Suite, Building




ex: 111-11-1111
PRINCIPAL INFORMATION
Note: All Principal information is required and should include the business owner's personal information only




ex: 111-111-1111



ex: 123 SW Main Street

ex: Suite; Building



COMPANY INFORMATION



STATE ID/ TAX BUSINESS REGISTRATION INFORMATION




If applicable

If applicable

PROGRAM INTEREST 

ADDITIONAL INFORMATION






tooltip text
\

InComm North Asia

\

InComm Europe

\

InComm Latin America

\

InComm North America

\

InComm Australia & New Zealand

\

InComm Nordics