Partner Referral Form | Canada

First Name is required Last Name is required Company Name is required Please enter a valid telephone number Please select a province Referring Employee First Name is required Referring Employee Last Name is required Referring Company Name is required Please enter a valid referring telephone number Please choose a current processor Please indicate if the prospect is expecting Chase to call

Complete this form with information about the merchant prospect and about your company. A Chase Paymentech sales representative will contact you and your merchant regarding payment processing. Thank you for referring your customers to us.

* = Required Field. Prospect Contact Information
* First Name	* Last Name

* Company Name	Title

Email	* Phone

Address	City

* Province	Postal Code

The merchant is expecting a call from Chase Paymentech	If the merchant currently accept payments, please choose your processor
Yes No
Partner (Your) Contact Information
* First Name	* Last Name

Employee ID, if applicable

* Company Name	Company Branch ID

Email	* Phone

Additional information:

Sales
1.866.833.8182

Customer Service
1.800.265.5158

Sales
1.866.833.8182

Customer Service
1.800.265.5158

Payment Solutions

Products & Services

Merchant Support

Partnership

Contact Us

Sales 1.866.833.8182

Customer Service 1.800.265.5158

Payment Solutions

Products & Services

Merchant Support

Partnership

Contact Us

Sales
1.866.833.8182

Customer Service
1.800.265.5158