Pharmacy Partner Application

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

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

WiFi (Portable Wireless Connection - Device has a built in scanner)

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

Is the Billing Address different from the Company Address?

YesNo

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

Principal Phone

ex: 111-111-1111

Business Owner Title

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

Limited Liability Type

C = C corporationS = S corporationP = partnership

If "Other" is selected, enter other company type here

STATE ID/ TAX BUSINESS REGISTRATION INFORMATION

Type of Business

Federal ID/EID

NPI Number

Dun & Bradstreet #

If applicable

SIC

If applicable

Number of year(s) in business

PROGRAM INTEREST

Which Program are you interested in?

ADDITIONAL INFORMATION

Display Designation (choose one):

Vanilla Service Option:
I would like to offer the Vanilla® Visa products

YesNo

I would like to offer the Vanilla® Reload Network

YesNo

How did you hear about us?

If "Other" is selected, how else did you hear of us?