HFD ENROLLMENT FORM

Business Info:

Legal Business Name:(Required)

Doing business as:(Required)

Legal Entity Type (LLC, S-Corp, C-Corp, Partnership, etc)(Required)

State Formed:(Required)

Tax ID or EIN number(Required)

Website(Required)

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Contact Info

Office Manager / Decision Maker (decision maker for refunds, cancellations & etc.)(Required)

Office Manager / Decision Maker Email:(Required)

Office Manager / Decision Maker Phone:(Required)

Dispute Resolution Contact (For disputes/chargebacks)(Required)

Dispute Resolution Contact Email(Required)

Dispute Resolution Contact Phone(Required)

Principal Info:

Name of Principal Owner(Required)

Title(Required)

Principal Owner Phone(Required)

Principal Owner Email(Required)

Location

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I am enrolling for:

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I am enrolling for:

One Location

Multiple Locations

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Banking Information:

Bank Name (Should match voided check or bank letter)(Required)

Official Business Name on Bank (Should match voided check or bank letter)(Required)

Routing Number (Should match voided check or bank letter)(Required)

Account Number (Should match voided check or bank letter)(Required)

Signature

Authorized Signer First & Last Name:

Authorized Signer Position:

Date

Signature

A copy of the principal owner(s) VALID ID must be attached to this application(Required)

Max. file size: 256 MB.

A voided check or bank letter must be sent along with this form to verify funding account information(Required)

Max. file size: 256 MB.

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Address:

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I am enrolling for:

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I am enrolling for: