"*" indicates required fields Subscription AgreementPartner First Name Partner Last Name Partner Sales Code Merchant Email* Merchant InformationCorporate Business Name* DBA Name* Business Phone Number* Tax ID#* Type of Business* Business Type*Business TypeCorporationPartnershipProprietorshipNon-ProfitLLCYears in Business* Business Address* City* State*StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code* Billing Address (if different than above) Yes Business Address* City* State*StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code* Bank Name* Routing Number* Account Number* Description of Leased EquipmentSchedule of PaymentsSubscription Term*Subscription Term24 Months36 Months48 MonthsTotal Monthly Subscription Charge* Total Subscription Cost* Voided Check*Accepted file types: pdf, doc, docx, xls, xlsx, Max. file size: 5 MB.Driver's License*Accepted file types: pdf, jpg, png, jpeg, Max. file size: 5 MB.Subscription AcceptanceTitle* Print Name* Personal GuarantyPrint Name* Home Phone Number* Home Address* City* State*StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code* DOB* MM slash DD slash YYYY Social Security Number* CAPTCHA Equipment Type*Select One...Clover Station DUOClover Station SoloClover Gen 3Clover Flex 2nd Gen w/ Starter KitClover Flex WifiClover Flex (US, Wi-Fi Only)Clover Mini Wi-FiClover Cash drawerClover Barcode ScannerThermal Kitchen PrinterQuantity*Select One...12345Unit Price (per device)* AddRemoveCommentsThis field is for validation purposes and should be left unchanged.
