Authorized Payment Center

Name (required)*

Business name (required)*

DBA (required)*

Address 1 (required)*

Address 2

City (required)*

US state (required)*

Zip code (required)*

Mobile Phone (required)*

Email (required)*

Store type
—Please choose an option—Authorized ShipperBig Box retailerC-storeChain storeWireless storeOther

Preferred Account type
Prepaid (deposit with cash or credit/debit)

Number of years in business

Products of Interest
H2O WirelessRed PocketLycaAT&T, VerizonT-MobileInternational Mobile Top-UpDomestic Bill PayALL

I have read the Terms of service (required)*
Yes
Click here to view Terms and Services

I have completed the W-9 form (required)*
Yes
Click here to fill out W-9

I have completed the ACH (required)*
Yes
Click here to fill out ACH

*The documents listed in the links above are required to open your account. Please take a few minutes to complete the forms via Docusign (click the link to go to Docusign) and submit them before clicking “Send” and completing your registration

How did you hear about us? (required)
Account RepresentativeInternet AdPartner ReferralMember of Authorized RetailOther