SeniorDiscounts Card Business Registration


BUSINESS DETAILS
Business Name:  
More than one location:  
Select a Category:  
Add Category:
(if not listed above)
  
Select a SubCategory:  
Add SubCategory:
(if not listed above)
 
Address 1:  
Address 2:  
City:  
State:  
 
Zip/Postal Code:  

If your business has multiple locations, please
fill out this form for one of the locations and we will contact you to help you
add the other locations.

BUSINESS CONTACT INFORMATION

Local Phone Number:  

(ex: 123-4567) 
Fax Number:  

(ex: 123-4567)
Toll Free Number:  

(ex: 123-4567)
E-mail Address:  
 

Website Address:

 
 

BUSINESS DESCRIPTION

Please briefly tell us and our SeniorDiscounts Card members about your business:
 
   

SENIOR DISCOUNT INFORMATION:

Senior Discount Offer:  
 
 
 
Senior Discount Restrictions:
(if any)
 
 
Age requirement   

PRIMARY CONTACT INFORMATION:

Contact’s Name:

 

Contact’s Phone Number:

 

(ex: 123-4567)

Contact’s E-mail Address:

 
 
(This e-mail address will also be your username when logging in.)
Password:

Confirm Password:

E-mail Format:

  

   

MAILING ADDRESS (IF DIFFERENT FROM ABOVE)

Address is same as above:

Address 1:

 

Address 2:

 

City:

 

State:

 

Zip/Postal Code:

 

TERMS AND CONDITIONS:

Please read the Business Terms and Conditions
before completing this registration.
Do you agree with the Terms and Conditions?  
 
   

SUBMIT YOUR INFORMATION

If you are satisfied that all of the information you have entered in the registration
form is correct, please click the “Submit” button below.
 
After you submit your business application, we will contact you within one week.
 
 

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