Elavon Merchant Processing Form

The following secure form provides Elavon the information needed to establish your merchant account.
This allows your plan’s membership fees to be deposited directly into your bank account.

Elavon Merchant Application

Practice Information

Dental Practice Physical Addess

Apartment/suite #

City

State

Zip/Postal

Dental Practice Legal Address

Address Line 1

Apartment/suite #

City

State

Zip/Postal

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