*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 OneEBusinessCrossSellEvergreenGreat 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 OneCS1CS2CS3CS4PAYCS1PAYCS2PAYCS3PAYCS5B2B1EBiz1EBiz2EBiz3EBiz4EBiz5EBiz6EBiz7AKCA10CA12CA14CA15FI-CA15FI-WAMTORPAYCA13PAYORWAWA3WAMTFI-IS1FI-IS2FI - MI1FI - OH1FI-OHFI-PA2INKYMIMI2OH1OH2OH3OH4PA2PAYINPAYKYPAYMI2PAYOH1PAYOH3PAYPA2PAYPA3HSCMPAYSE BANK HSCSEHSCSTDealerSE LSS1MJ1DCMetroDCVAFI-DCMetroFI-DCVAFI-NJ1FI-NJ2FI-PA1FI-PA4FI-VA2MDDENJ1NJ2NJ4PA1PA3PA4ARCO2NECO3CO4NMFI-AKFI-CO4FI-ID1FI-KS1FI-NE1FI-NVIAIDMO1/KSNENVPAYMidwestPAYMO1/KSUTFI-IL1FI-IL2FI-IL3FI-MO1FI-SD1IL1IL2IL5MN1MO2IL3MO3ILNDSDPAYIL1PAYMNPAYMN2PAYMOILPAYWIWI1WI3BOS1BOS2CT2FI-BOS1FI-NY1FI-NY3FI-NY4MEME2NY3NY4NY5NYC1NYC2NYC3PAYBOSPAYMACTPAYNJ1PAYNY1PAYNY4PAYPAPAYPA1NJ1PAYPANJPAYVAWVBDR1BDR2SalesDev1SDRHSC1FI-GA2FI-NC1FI-NC4FI-SC1FI-TN2GA1GA2GA3NC1NC2NC4PAYGA1PAYNCPAYSCPAYTNSC1TN1TN2FI-TX2FI-TX3OKOK2PAYOKPAYTX1PAYTX3PAYTX5TX1TX2TX3TX4TX5TX6TX7WTXAZAZ3CA1CA2CA3CA3ACA5FI-AZ1FI-AZ2HIPAYAZ2PAYAZ3PAYCA2PAYCA4PAYCA5ALFI-FL2FI-FL5FI-FL6FL1FL1aFL2FL3FL4FL5FL6LAMSPAYALPAYFL1PAYFL2PAYFL4PAYLAPAYMSPartner 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 UnionTracking 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.