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DealerID
Personal Information
Supplier*
Your First and Last Name*
Full Name
Email*
Business Phone*
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Mobile Phone
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How did You hear about POWERpay®
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Are you an owner?*
- Yes
- No
Business Information
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Other Business
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Sponsor No. (if applicable)
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Legal Business Name*
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Federal Tax ID#
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Reference Number
Business Name*
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In Business Since
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In Business Since
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Referred By
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Business Structure
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Type of Service / Product Business Offers
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Annual Sales Revenue*
Annual Finance Volume (in $)*
Website Address*
Primary Business*
Secondary Business*
Secondary Business*
Secondary Business*
Secondary Business*
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Annual Consumer Finance Volume (in $) *
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Average Ticket (in $)
Physical Address*
Street Address Address Line 2 City State ZIP Code
Affiliate Group / Referred by
Select your Atlas ProPlus level*
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Mailing Address*
Street Address Address Line 2 City State ZIP Code
Principal, Partner or Owner Information *
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Owner Full Name
Full Name
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Owner's Email
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Telephone
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Birthdate
MM slash DD slash YYYY
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Owner Since
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Social Security Number
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% Ownership
Please enter a number from 1 to 100.
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Owner Home Address
Street Address Address Line 2 City State ZIP Code
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Owners
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Add second owner
- Yes
- No
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Owner Full Name
Full Name
Email*
Phone*
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Birthdate
MM slash DD slash YYYY
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Owner Since
MM slash DD slash YYYY
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Social Security Number
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% Ownership
Please enter a number from 1 to 100.
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Address
Street Address Address Line 2 City State ZIP Code
Add third owner*
- Yes
- No
Owner Full Name*
Full Name
Email*
Phone*
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Birthdate
MM slash DD slash YYYY
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Owner Since
MM slash DD slash YYYY
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Social Security Number
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% Ownership
Please enter a number from 1 to 100.
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Address
Street Address Address Line 2 City State ZIP Code
Add fourth owner*
- Yes
- No
Owner Name*
Full Name
Email*
Phone*
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Birthdate
MM slash DD slash YYYY
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Owner Since
MM slash DD slash YYYY
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Social Security Number
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% Ownership
Please enter a number from 1 to 100.
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Address
Street Address Address Line 2 City State ZIP Code
Add fifth owner*
- Yes
- No
Owner 5 Full Name*
Full Name
Email*
Phone*
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Birthdate
MM slash DD slash YYYY
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Owner Since
MM slash DD slash YYYY
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Social Security Number
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% Ownership
Please enter a number from 1 to 100.
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Address
Street Address Address Line 2 City State ZIP Code
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- Clicking the checkbox and submitting this application, you are certifying that you have read and agree to the Disclosures and Program Agreement. Sole Proprietorships and Partnerships: We may verify credit history and secure credit reports of Applicant, principals, owners, or partners. You hereby approve any third party to provide reports to PowerPay. I certify that the information submitted is true, accurate and complete.
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Business Information

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