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Agency Information

Legal Name *

DBA Name

Physical Address

Street Address *

City *

State *

Zip Code *

Mailing Address is different from Physical Address

Mailing Address

Street Address

City

State

Zip Code

Agency Website URL

Customer Help Number *

Federal Tax ID *

Time Zone *

Banking Information

Account Type *

Bank Routing Number *

Bank Account Number *

Check Image or Bank Letter * Upload a clear image or PDF of a voided check or bank letter

W-9 * Upload W-9 form

Contact Information

Reconciliation Contact 1 *

Name *

Title *

Email *

Reconciliation Contact 2

Name

Title

Email

Reconciliation Contact 3

Name

Title

Email

Contact Numbers

Phone Number *

Fax Number

Additional Notes

Notes/Comments

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