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Paycare Program looks forward to servicing you!

How did you hear about us?*

Facility Name*

Primary Contact Name*

Facility Address*

Phone Number*

Email Address*

Membership Type (Check All That Apply) *

Facility Type (Check All That Apply) *

Membership Level*

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

# of Facilities to Join

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

I acknowledge that My Referral might obtain less than the amount owed to my facility.

Add'l Service(s) Requested

I Understand that I am to Send a Copy of a Businss License OR Tax ID#. I Havethe Option to Send a 'Void' business Check for Direct Deposit.
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 Levels: 


#1:

Starter Mbrshp

(Funds sent to the     family you refer) 

       -No fee to your business, but $ are in control of your customer.


#2:

Full Mbrshp

(Funds sent directly to your business)

      -10% fee per transaction; your   

business remains in control of the $ at all times.


        FACILITY MEMBERSHIP

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