Application: Page 3 (Docs)

You’re almost done!

Please provide us with the 2 required documents below. Additionally, we’ll need your banking information so we can fund transactions into your account. Once complete, our team will quickly setup your account and reach out to schedule training. We look forward to working with you!

Documentation

Copy of a Voided Check

Copy of a 2nd Voided Check (if applicable)

Driver's License or Government Issued ID

Deposit Account Information

Bank Name

Routing Number

Account Number

Is your Deposit Account same as your Fee Account?

Fee Account Information

Bank Name

Routing Number

Account Number

Hidden Fields

App ID

Account ID

Contact ID

Lead Id

Patient OppID

Merchant OppID

Want Merchant Financing?

By clicking the “I Agree” checkbox below, I hereby acknowledge and agree: (i) that I am authorized to submit this Application on behalf of Client and that I have direct knowledge of the information provided in this Application; (ii) that all information submitted in connection with this Application is true, accurate and complete; (iii) that on behalf of myself and Client, I authorize ClearGage, and its agents, affiliates, representatives, subcontractors, payment processors, and factors; to obtain consumer reports from consumer reporting agencies about me and the Client to verify the information provided in this Application and consent to the collection, use and disclosure of such information about me personally and the Client, and Client’s proprietors, partners, principal owners or officers, for this purpose, including, but not limited to, the sharing and exchange of such information with credit reporting agencies, credit bureaus or other third party providers to obtain or verify financial condition, employment history, education background, character references, civil and criminal history records, licensure qualifications and any other records of me and the Client; (iv) that on behalf of myself and Client, I authorize ClearGage to use the reports on me and Client received from consumer reporting agencies for marketing and administrative purposes; (v) that I have read, and accept, on behalf of Client, the Loan Program Agreement and the Master Services Agreement and all applicable Schedules (e.g. Business Associated Addendum, Sub-Merchant Schedule, Funding Services Schedule, etc.); (collectively, the “Agreements”) and (vi) that Client's acceptance of any amendment, restatement, supplement or any other modification to the Agreements will occur when Client first uses the ClearGage services following notice of any such amendment, restatement, supplement or modification. If you are not able to access and review the Agreements, please contact our Customer Service Center at 800-236-3206 to request a copy.

I Agree

By clicking the “I Agree” checkbox below, I hereby acknowledge and agree: (i) that I am authorized to submit this Application on behalf of Client and that I have direct knowledge of the information provided in this Application; (ii) that all information submitted in connection with this Application is true, accurate and complete; (iii) that on behalf of myself and Client, I authorize ClearGage and American Express Travel Related Services Company, Inc. (“American Express”), and their agents, affiliates, representatives, subcontractors, payment processors, and factors; to obtain consumer reports from consumer reporting agencies about me and the Client to verify the information provided in this Application and consent to the collection, use and disclosure of such information about me personally and the Client, and Client’s proprietors, partners, principal owners or officers, for this purpose, including, but not limited to, the sharing and exchange of such information with credit reporting agencies, credit bureaus or other third party providers to obtain or verify financial condition, employment history, education background, character references, civil and criminal history records, licensure qualifications and any other records of me and the Client; (iv) that on behalf of myself and Client, I authorize ClearGage and American Express to use the reports on me and Client received from consumer reporting agencies for marketing and administrative purposes; (v) that I have read, and I accept on behalf of Client, the Loan Program Agreement and the Master Services Agreement and all applicable Schedules (e.g. Business Associated Addendum, Sub-Merchant Schedule, Funding Services Schedule, etc.); (collectively, the “Agreements”) and (vi) that Client's acceptance of any amendment, restatement, supplement or any other modification to the Agreements will occur when Client first uses the ClearGage services following notice of any such amendment, restatement, supplement or modification. If you are not able to access and review the Agreements, please contact our Customer Service Center at 800-236-3206 to request a copy.

I Agree

Contact Information