Rarebreed

Allows more business information and file uploads

Business Name*
Clinic Email Address
Owner's First Name*
Owner's Last Name*
Owner's Percent Ownership (%)*
Please enter a number from 0 to 100.
Phone*
Email*
Industry*
Are you currently processing credit cards?*
Average Monthly Volume*
Average Transaction Amount*
DBA Address (physical location)*
Street Address Address Line 2 City State ZIP Code
Website
Legal Business Name
EIN/TIN (what you file taxes under)
Does Gravity already process for another clinic under the same EIN?*
- Yes
- No
If yes, please list the name of the clinic:
Legal Address (as registered with the Secretary of State)
Same as DBA (physical location)

Street Address Address Line 2 City State ZIP Code
Primary Device
Primary Device Quantity
Secondary Device
Secondary Device Quantity
Desired "Go Live" Date
Month
Day
Year
Upload a current processing statement
This is required to approve your account, unless you are a brand new clinic.
Max. file size: 10 MB.
Upload a voided check*
If you do not have checks, you may attach a letter from your bank signed by a bank representative that includes both your routing and account number.
Max. file size: 10 MB.
Notes
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