Form

Company name*

Company Type*

Company Phone*

Company Website URL

Street address*

Street address 2

City*

State/Region*

Postal code*

Tax ID*

Please enter your tax ID with no dashes or spaces.

Company Billing Email*

Enter the address for payment notifications and acceptance. If you want to use separate email addresses for each location, submit this form for each one with the corresponding Company ID. For more than 5 locations, call 888-409-8662 or email support@getcarepay.com to simplify your enrollment.

Accepted Payment Types*

Physical Check

ACH/EFT

Instant Virtual Card

Vendor Default Payment Type*

Your First name*

Your Last name*

Email*