This site requires javascript to be enabled on your browser. Please enable Javascript and try again.
Referred by: The Merchant's Matchmaker
Business Information
Business Name:
Federal Tax ID:
digits only
Business Type:
RDI Fee:
Return Deposit Item Fee charged to the merchant
by the depositing bank for returned checks.
Physical Address:
City:
State:
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
AS
DC
FM
GU
MH
MP
PR
PW
VI
AA
AE
AP
State is required.
Zipcode:
Use a different Mailing Address
Mailing Address:
Address is required.
City:
City is required.
State:
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
AS
DC
FM
GU
MH
MP
PR
PW
VI
AA
AE
AP
State is required.
Zipcode:
Zip code is required.
Contact Information
Owner Name:
Contact Name:
Phone #:
Fax #:
Email:
Website:
Comments:
I want Check Assist or a Check Assist affiliate to handle all secondary collections.
Send my items to collections automatically
I want to manually release my items to collections
I will attempt collections on my own so please notify me instead of sending items anywhere.
I will have my Collection Agency contact you about sending items to you for collection. Please have them call us at (888-436-5101 Ext 7)
1) Account Name:
Route:
Re-Enter Route:
Account:
Re-Enter Account:
Add Another Account
2) Account Name:
Route:
Re-Enter Route:
Account:
Re-Enter Account:
Add Another Account
3) Account Name:
Route:
Re-Enter Route:
Account:
Re-Enter Account:
Add Another Account
4) Account Name:
Route:
Re-Enter Route:
Account:
Re-Enter Account:
Add Another Account
5) Account Name:
Route:
Re-Enter Route:
Account:
Re-Enter Account:
Add Another Account
6) Account Name:
Route:
Re-Enter Route:
Account:
Re-Enter Account:
Add Another Account
7) Account Name:
Route:
Re-Enter Route:
Account:
Re-Enter Account:
Add Another Account
8) Account Name:
Route:
Re-Enter Route:
Account:
Re-Enter Account:
Add Another Account
9) Account Name:
Route:
Re-Enter Route:
Account:
Re-Enter Account:
Add Another Account
10) Account Name:
Route:
Re-Enter Route:
Account:
Re-Enter Account:
Add Another Account
Account to deposit collected funds into:
Bank Account to Receive Collected Funds
Route:
Re-Enter Route:
Account:
Re-Enter Account:
Acct. Type:
Business Checking
A business account is required to
use the Check Chase Online service.
This form is being prepared by a sales agent on the merchant’s behalf.
Either this option must be deselected or a sales agent name must be entered below.
Sales Agent Name:
By electronically signing this form, I certify that I have read and understand the service
Terms & Conditions
.
Full Name:
If this signup is not being prepared by a Sales Agent, then you must electronically sign the form.
Date Signed:
Do you have a pending signup request?
Sign in
to check your status.
Email:
Confirmation Code:
Lost your Confirmation Code?
Re-send Confirmation Code