OfficeTeller Affiliate ACH EFT software

Affiliate Enrollment

Affiliate Home Page

Independent Sales Organization Application

Your Name:
Company:
Address:

City:	State: Zip:
Telephone:
Fax:
Email:

Additional Required Information
How did you hear about OfficeTeller^TM:
Type of Affiliation Desired:
Your "Referring Source E-Mail":	Example: ReferralSource@E-mail.com
Your Website Address ("URL"):	Example: http://www.yourcompany.com
Type of Business Entity:
Federal Tax ID Number (or SSN):
Years in Business:
Describe Type of Goods / Services Sold:
Monthly Sales Volume:
Average Sale Amount:
Your Bank Information
Bank Name:
Address:

City:	State: Zip:
Contact Name:
Bank Telephone Number:
Bank Routing Code (9 digits):	Bank Account Number:
Comments:

Remember, after you submit this Online Independent Sales Organization Application we will contact you and transmit the Business Referral Agreement.

For more information:
(866) 927-7180