*Warning - It is important that a conversation with the potential partner has occurred before submitting a lead through this form. You will need your Partner's correct business information and their consent as they will receive a legal binding contract from Heartland Payments - via DocuSign. Once complete and submitted, this information will be added to SalesForce and reviewed by your Senior Director of Business Development for next steps to contract. For questions, please e-mail your respective Senior Director of Business Development.Heartland Sales InformationRM/SPA Name*Region*Please Choose OneEBusinessEvergreenGreat LakesMid AtlanticMidwestPayroll AtlanticNorth CentralNortheastSouth AtlanticSouth CentralSouth PacificSoutheastRM/SPA Email* VP*VP*VP*VP*VP*VP*VP*VP*VP*VP*VP*VP*VP*RM/SPA Phone*DM Name*Division*Please Choose OneAKALARAZAZ2AZ3AZ4CA1CA10CA11CA12CA13CA14CA15CA16CA2CA3CA3ACA4CA5CA6CA7CA8CA9CO2NECO3CO4CS1CS2CS3CS4CS5CS6DCMetroDCVAEBiz1EBiz2EBiz3EBiz4EBiz5EBiz6EBiz7FL1FL1aFL2FL3FL4FL5FL6GA1GA2GA3HIIANEIL1IL2IL4IL5IL6ININ2KYLAMA1RI2MA2MDDEMDDE2MEMIMI2MI3MJ1 (National Accounts)MN1MN2MN3MO1/KSMO2IL3MO3MSMTNC1NC2NC4NDSDNENHVTNJ1NJ2NJ3NJ4NVNV2NY1NY10NY12NY13NY2NY3NY4NY5NY6NY9OH1OH2OH3OH4OH5OH6OKOK2OROR2PA1PA2PA3PA4NJ4PA4NJ5PA5PAYALPAYARPAYAZPAYAZ2PAYAZ3PAYBOSPAYCA1PAYCA10PAYCA12PAYCA13PAYCA2PAYCA4PAYCA5PAYCOPAYCO2PAYCO3PAYDCMetroPAYFL1aPAYFL2PAYFL4PAYGA1PAYGA4PAYIANEPAYIL1PAYIL2PAYINPAYKYPAYLAPAYMACTPAYMDDEPAYMI2PAYMNPAYMO1/KSPAYMO2IL3PAYMOILPAYMSPAYNCPAYNC2PAYNEPAYNJPAYNVPAYNY1PAYNY3PAYNY4PAYOH1PAYOH2PAYOH3PAYOKPAYORPAYOR2PAYPAPAYPA1NJ1PAYPA2PAYPANJPAYSCPAYTNPAYTX1PAYTX2PAYTX3PAYTX5PAYVAWVPAYWAPAYWIPAYWI2PAYWTXNMRICTSC1TN1TN2TN4TX1TX2TX3TX4TX5TX6TX7TX9UTVAWVWAWA2WA3WI1WI2WI3WTXNMPartner InformationPartner DBA Name*Partner Legal Name* Legal Name Same As DBA Name Partner WebsiteName on Agreement*DBALegalSigner Name* First Last Signer Title*Signer Email* Signer Phone*Business Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State ZIP Code Partnership ScoringHas Influence Over Decisions of Customers/Members (1 Lowest/5 Highest)*12345Number of Customers/Members*Please enter a number from 1 to 10000.How Many of these Customers/Members Should We Expect to Convert/Sign?*List 2 MIDs or Client IDs this Partner has referred to you. THIS IS MANDATORY AND WE MUST ACCOUNT FOR THEM.*POS Brands Sold/Serviced (N/A if Not Applicable)*Partner Industry*Please Choose OneSoftware ProviderProfessional ServicesFinancial InstitutionHealth ServicesAssociations & Network GroupsMarketing ServicesBusiness ServicesPersonal ServicesFranchiseEcommOtherUnknownReferral Business Type* Education Billing Pharmacy Retail Restaurant Grocery Transportation Micro Payments Hospitality Healthcare Dental Veterinary Gaming/Entertainment Parking Online Orders Accounting/QuickBooks Real Estate/Property Management Salon Government Golf Liquor eComm - ProPay eComm - Online Payments Referral Business Type* Accounting/Quickbooks Attorney/Legal Services CPA Billing Bookkeeping Enrolled Agent/Tax Workers Comp Insurance Agent Health/Benefits Insurance Broker Insurance Miscellaneous Financial Advisor HR Consultants Business Consulting Commercial Real Estate/Development Real Estate/Property Management Architecture & Engineering Construction/Utilities/Contracting Petro/Energy Referral Business Type* Banks Credit Unions Referral Business Type* Healthcare Dental Pharmacy Referral Business Type* Healthcare Dental Automotive Pharmacy BNI Restaurant Retail Hospitality Associations & Membership Organizations Chambers Referral Business Type* Advertising Media Creative Print Marketing Web Design Referral Business Type* Trade IT/Communications Hospitality Retail Restaurant Referral Business Type* Salons/SPAs Barber Shops Referral Business Type* ProPay Online Payments Partnership DetailsProducts of Interest Under Revenue Share Card Processing Payroll Choose All That AppyProposed Revenue Share*Business Types to be Referred to Heartland*Partner Type*Referral Services Partner (RSP)Integrated Partners (Custom Software)Trusted DealerTrusted DeveloperHFDPPayroll APPayroll RSPBank / Credit Union / Financial InstitutionTracking Only - No Rev SharePlease add any relevant information about this partnership (how you connected with them and how you/Heartland will benefit from this partnership).Please e-mail [email protected] if you have any issues with the above submission form.