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: |
– | ||||||||
|
|||||||||
|
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.
|
|||||||||
|
|
|||||||||