Copy of Begin Facility Membership!

Paycare Program looks forward to servicing you!

Facility Name*

Primary Contact Name*

Facility Address*

Phone Number*

Email Address*

Membership Type (Check All That Apply) *

Paycare-PLUS(Childcare-12th Grade & Extra-curricular Paid to Your facility)

Paycare HOME (Mortgage/Rent/Repairs/Utilities Paid to Your Facility)

Paycare HOME *addendum("Non-Eviction Lease" Guarantees Tenants' rents to Your Facility after 2 on-time pmts; $125 per site)

Paycare MEDICAL (doctor visit costs Paid To Your Office)

Paycare SCHOLAR (college/tuition costs Paid To Your Institution)

Paycare AUTO (Repairs, Past-due pmts, down pmts Paid To Your Shop or Office)

Paycare BENEVOLENCE (Community members, Church members & Pledges)

Facility Type (Check All That Apply) *

Membership Level*

Full membership to email copy of Business license to membership@paycareprogram.org

FULL [Full Membership (Receive direct payments via mail or direct deposit at $125/Site)] *Business Lic required.

STARTER [Referring Only (Payments mailed to the facility + 5% Non-Member, per-trans fee)]

PARTNER [Paycare sets up your office(s) to control your Payment Protection "Pay Incentives" for your customers without paying any processing fees to our office, at $1,250/Site.] *Business Lic required.

# of Facilities to Join

Referrals (Parent Name & Ph#, Child Name & Date of birth):

I acknowledge that My Referral might make a partial payment, less than the amount owed to my facility.

If so, I will accept a 'Pay Incentive' or Pledge for a lesser amount

If so, I will not accept a 'Pay Incentive' or Pledge for a lesser amount

Add'l Service(s) Requested

For my 'Non-Eviction' continued payments, I choose:

I choose to receive 85% of the regular payment amount in order to continue payments in 10-15 business days.

I choose to receive 90% of the regular payment amount in order to continue payments in 30 business days.

I Understand that I am Required to Send a Copy of a Businss License OR Tax ID#. I Havethe Option to Send a 'Void' business Check for Direct Deposit. *Otherwise, payments will be mailed to me]

Business License Copy

Copy of Tax ID#

Copy of 'Void' Check (optional)

Upload Busines License Copy

Upload Tax ID Copy

Upload Business Check (optional)

Authorized Signature (I acknowledge that my typed signature is equivalent to my signing via ink to paper as if I had signed the document with ink on paper in accordance with the Uniform Electronic Transactions Act (UETA) and the Electronic Signatures in Global and National Commerce Act (E-SIGN) of 2000.))

Date of Signature

Thank you for contacting us. We will get back to you within 24 to 48 hours.

Complete the form

on the left to receive

'Pay Incentives'

on behalf of your customers!

Mbrshp:

#1: Full Mbrshp

(Funds sent directly

to your business)

-3% fee per transaction; your

business remains in control of the $ at all times.

Click Here To: Download Your "OAN" appl! (Repeat Funding in only 7-10 days!) (400+ credit/$10K monthly income required)

Click For Client Referral Form

FACILITY MEMBERSHIP