RRR 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.

RRR – Elavon Merchant Application

Practice Information

Dental Practice Legal Name*

Dental Practice DBA

Practice Phone Number*

Tax ID Number*

Dental Practice Physical Addess

Dental Practice Physical Addess

Dental Practice Physical Addess

Apartment/suite #

Apartment/suite #

City

City

State

State

Zip/Postal

Zip/Postal

Legal Address Same as Above

Dental Practice Legal Address

Dental Practice Legal Address

Address Line 1

Address Line 1

Apartment/suite #

Apartment/suite #

City

City

State

State

Zip/Postal

Zip/Postal

State of Incorporation

Type of Ownership*

Number of Years in Business*

Annual Practice Gross Revenue*

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© Copyright SmileMore DSP | All rights reserved.

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