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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

# 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.

Add'l Service(s) Requested

With Pay Incentives & Non-Eviction Leases, I Understand The Following:
For my 'Non-Eviction' continued payments, I choose:
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]
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!




#1: Full Mbrshp

(Funds sent directly

to your business)

      -3% fee per transaction; your   

business remains in control of the $ at all times.


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