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 $1700/Site)] *Business Lic required.

STARTER ['Try Before I Buy' (Payments mailed to the facility; $0/site + 5% Non-Member, per-trans fee)] *TAX ID# required.

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 $2,250/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 'Continued' payments, I choose:

I choose to receive 85% of the regular payment amount in the event of 'continued' payment (funds paid in 1-10 business days).

I choose to receive 90% of the regular payment amount in order to continue payments I*funds paid in 10-12 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] Required

Business License Copy

Copy of Tax ID#

Copy of 'Void' Check (optional)

Upload Busines License Copy

Upload supported file (Max 15MB)

Upload Tax ID Copy

Upload supported file (Max 15MB)

Upload Business Check (optional)

Upload supported file (Max 15MB)

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)

Mbrshp #2:

Partner Mbrshp

(We empower YOU

to process & control "Payment Protection" for your own custs!

For a one-time

Per-site, Set-Up Fee

Your business

remains in control

of funds at all times.

"Starter" for

Non-members:

Try before you buy!

(Funds mailed

directly to you!)

5% per-trans fee

-That's right! We will not turn away custs

of non-members!

So, payments can

still continue for

you until you join!

Click For Client Referral Form

FACILITY MEMBERSHIP