Merchant Processing Form

Name: *

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Practice Name: *

Contact Name: *

Phone *

Rep: move Account

Fax:

Email: *

Current Equipment:

Account Number:

Are you an AIDA-Align Member? *

Nashville Dental Account Rep:

Please Upload Your Current Processing Statement

Click or drag a file to this area to upload.

I have included my most recent merchant services statement for my free, no obligation comparison. *

I have included my most recent merchant services statement for my free, no obligation comparison.

Let’s move forward with the application. *