* indicates a required field

Company Name: *

Type of Company (i.e. – corporation, professional corporation, limited liability corporation, partnership or other): *

Company Address: *

City:

State:

Zip:

Company Website (No Social Media Links Accepted): *

Contact Name: *

Job Title: *

Email Address: *

Telephone Number: *

Describe Your Company/Services: *

500 character limit

Total years your company has been in business:

BBB Rating: *

Is your company BBB Accredited? *

If a Higher Education merchant, please select your regional accreditation institution:

Is there any open litigation pending related to your company products and/or services? *

If yes, describe the open litigation:

Is your company compliant with PCI standards? *

When was the last time your company conducted a PCI audit? (MM/DD/YYYY)

What discount will you be providing our members? *

Note: The discount offered must not be available to the general public.

Area of Discount: *

Which LifeCare client organization are you looking to provide your discount to? *

Referred By:

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Disclaimer
All submissions to LifeCare, Inc. (“LifeCare”) to become a LifeMart Merchant are subject to approval in the sole discretion of LifeCare. You certify that you have the authority to complete the Request to Become a LifeMart Merchant form (“Merchant Application”), and all information included by you in the Merchant Application is true and accurate. You understand that LifeCare maintains strict criteria which Merchants must meet in order to eligible for acceptance as a LifeMart Merchant, including but not limited to BBB Rating, Insurance limits, years in business, etc. In addition, Merchants in the following areas are not eligible to become LifeMart Merchants, alcohol, firearms, tobacco, lewd services/products, and/or any other products and services determined in LifeCare’s sole discretion not to be eligible and/or appropriate for the LifeMart Platform. You further understand that if your Merchant Application is accepted you will be required to sign a LifeCare form of Merchant Agreement which will govern your relationship with LifeCare as a Merchant on LifeCare’s LifeMart platform.