Heartland Billing Solutions Certification Intake Form
Thank you for choosing Heartland Billing Solutions for your processing needs.  The following form is part of the overall integration process and used to gather general information about you and your system.  Please complete the form and reach out to billpayintegrationsupport@e-hps.com with any questions about the items contained within this document.
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Company Information
Please provide details about your company and the people that will be linked to this project.
Company Name *
Company Address *
Company Website *
Merchant Website Logo (we will use your logo from website URL unless otherwise specified)
Company Phone Number *
Business Contact *
Business Contact Email *
Business Contact Phone Number *
Developer Contact
Developer Contact Email
Developer Contact Phone Number
Who is the integration for?
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