Addendum | Heartland Partner

*Warning - This form is strictly used for existing trusted dealers and partners looking to add a Lending or Payroll Addendum.

Partner Information

Partner DBA Name*

Name on Agreement*

Signer Name*

First Last

Signer Title*

Signer Email*

Signer Phone*

Business Address*

Street Address City State ZIP Code

Products of Interest Under Revenue Share

Choose All That Appy

Please add any relevant information or notes here and we will follow-up.

Please e-mail [email protected] if you have any issues with the above submission form.

Partner Type*

Division*

Lead Status*