Merchant Registration

Apply to become a United Credit Merchant

If you have any questions contact enroll@unitedcredit.com.

Company Owners/Officers

Please enter all Owners with 25% or more ownership

Owner 1

Full Name *

Title *

Percentage Owned *

Address *

City *

State *	Zip code *

Date of Birth *

Personal Email *

Personal Cell *

(

)

–

Social Security Number *

–

Type of Ownership *

Enter details of Owner 2

Owner 2

Full Name *

Title *

Percentage Owned *

Address *

City *

State *	Zip code *

Date of Birth *

Personal Email *

Personal Cell *

(

)

–

Social Security Number *

–

Enter details of Owner 3

Owner 3

Full Name *

Title *

Percentage Owned *

Address *

City *

State *	Zip code *

Date of Birth *

Personal Email *

Personal Cell *

(

)

–

Social Security Number *

–

Enter details of Owner 4

Owner 4

Full Name *

Title *

Percentage Owned *

Address *

City *

State *	Zip code *

Date of Birth *

Personal Email *

Personal Cell *

(

)

–

Social Security Number *

–

Company

Corporate or Legal Name *

Business Name/DBA (if different)

Federal Tax ID number *

Business Address *

City *

State *	Zip code *

Primary Office Phone *

(

)

–

Field of Business *

Company website *

Number of locations *

Office Contact Full Name *

Office Contact Email *

Office Contact Phone – if different

(

)

–

Date Company Opened *

Average Financed Amount *

Estimated Annual Financing *

Business License Number *

Name of Licensed Professional *

How do you Offer Services to Customers? *

Do you have an existing location enrolled with United Credit? Enter it here

Verification

Please upload the following to help verify your account information. All images must be .jpg images, max 10Mb.

Upload Voided Check:

Upload Driver’s License:

Upload Medical/Business License:

UNITED CREDIT PROFESSIONAL APPLICATION. Submission of United Credit Professional Application (“Application”) establishes a consumer financing program with United Medical Credit, Inc. for the above-named person or legal entity (“Provider”) the terms of which are set forth in this Network Registration (Provider Direct) Form and the United Credit Provider Direct Terms and Conditions. By submitting this form, Provider hereby represents, acknowledges, agrees, authorizes and confirms the following:

If Provider is a legal entity, the applicant is executing this application as an officer of the Provider.
If Provider is sole proprietorship, the applicant is executing this Application in his or her individual capacity.
Provider has reviewed all provisions of this Application and all information provided herein is true and complete.
The above Tax ID number is the correct taxpayer identification number for the Provider.
Provider agrees to all terms and provisions of the United Credit Provider Medical Terms & Conditions, Retail Terms & Conditions (“Terms and Conditions”) and the HIPAA BAA which are incorporated by reference. You agree that United Credit may amend such Terms and Conditions, and you agree to be bound the Terms and Conditions and the HIPAA BAA that are set forth at https://www.unitedcredit.com/provider-terms/ at the time of signing the UC Disbursement Form.

Please carefully read the United Credit Provider Terms and Conditions and the HIPAA BAA that are available here and herein by reference. By submitting this form, you are entering into a binding contract with United Medical Credit, Inc., which shall govern the submission of transactions for financing. If Provider is a legal entity the signatory hereto represents and warrants that he or she is authorized to execute the Agreement on behalf of, and to bind, Provider on whose behalf he or she signs this Agreement.

I have read, understand and accept the above terms

Enter your Name below to confirm:

Date: 03/29/2025

All data is encrypted in transit

Your Name *		Your Email *		Your Phone Number *
Business Name *		If you have any questions about becoming a merchant contact enroll@unitedcredit.com.

Medical Loans

Retail Loans

Medical Loans

Retail Loans

Merchant Registration

Apply to become a United Credit Merchant

Apply to become a United Credit Merchant

Company Owners/Officers

Information previously entered

Owner 1

Owner 2

Owner 3

Owner 4

Company

Verification

Upload Voided Check:

Upload Driver’s License:

Upload Medical/Business License:

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