Partnering with Paya Services process:

• Complete form below and submit
• Relationship Manager will contact you within 48 hours
• Agreement and buy rate pricing will be forwarded to you

Contact Information

First Name*

Last Name*

Phone Number*

Email*

Verify Email*

Job Title*

Company*

Street 1*

Street 2

City*

State*
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Zip Code*

Current Processing Information (Optional)

Credit Card Processor(s)

# of Merchants activated with Credit Card services monthly
1-1011-2525+

# of Merchants activated with Check and ACH services monthly
1-1011-2525+

Additional Questions/Comments (Optional)