Heartland Partner | Submit Referral

*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 Information

RM/SPA Name*

Region*

RM/SPA Email*

VP*

RM/SPA Phone*

DM Name*

Division*

Partner Information

Partner DBA Name*

Partner Legal Name*

Legal Name Same As DBA Name

Partner Website

Name on Agreement*

Signer Name*

First Last

Signer Title*

Signer Email*

Signer Phone*

Business Address*

Street Address City State ZIP Code

Partnership Scoring

Has Influence Over Decisions of Customers/Members (1 Lowest/5 Highest)*

Number 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*

Referral Business Type*

Banks
Credit Unions

Referral Business Type*

Healthcare
Dental
Pharmacy

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 Details

Products of Interest Under Revenue Share

Card Processing
Payroll

Choose All That Appy

Proposed Revenue Share*

Business Types to be Referred to Heartland*

Partner Type*

Please 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.