LifeMart Works®! Request to Become a LifeMart Merchant

* indicates a required field

Company Name: *

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

State of Incorporation:

—Please choose an option—AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Company Address: *

City:

State:

—Please choose an option—AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

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: *

—Please choose an option—A+AA-B +BB –C +CC -D +DD –FNot Applicable

Is your company BBB Accredited? *

—Please choose an option—YesNoNot Applicable

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

—Please choose an option—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 Colleges

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

—Please choose an option—YesNo

Is your company compliant with PCI standards? *

—Please choose an option—YesNo

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: *

—Please choose an option—NationwideRegionalLocal

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

Referred By:

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.