LifeMart Works®! Request to Become a LifeMart Merchant * indicates a required fieldCompany Name: * Type of Company (i.e. – corporation, professional corporation, limited liability corporation, partnership or other): * State of Incorporation: ---AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingCompany Address: * City: State: ---AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip: Company Website (No Social Media Links Accepted): * Contact Name: * Job Title: * Email Address: * Telephone Number: * Describe Your Company/Services: * 500 character limitTotal years your company has been in business: BBB Rating: * ---A+AA-B +BB –C +CC -D +DD –FNot ApplicableIs your company BBB Accredited? * ---YesNoNot ApplicableIf a Higher Education merchant, please select your regional accreditation institution: ---Middle States Association of Colleges and SchoolsNew England Association of Schools and CollegesNorth Central Association of Colleges and SchoolsNorthwest Accreditation CommissionSouthern Association of Colleges and SchoolsWestern Association of Schools and CollegesIs there any open litigation pending related to your company products and/or services? * ---YesNoIf yes, describe the open litigation: Is your company compliant with PCI standards? * ---YesNoWhen 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: * ---NationwideRegionalLocalWhich LifeCare client organization are you looking to provide your discount to? * Referred By: Please enter the characters below: DisclaimerAll 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.