myEPIONES Distributor - Merchant Account Registration
This form is for myEPIONES Distributors who would like to set up an invite-only merchant account. Please do not fill this form out more than once.  Your request will send to our rep for processing.  We have been given a soft approval for all MD's in need of a merchant account.  (This is relevant if you are selling from inventory or point of sale.)

Once your information has been submitted, you will be asked to go through their application process.  There are a few forms to digitally sign and your account can be quickly opened.  You can begin charging through the new account immediately, but deposits may require 5-7 business days as your account needs to go through their underwriting.

Note:  This registration is for a pilot program -- it is in beta and confidential.
Sign in to Google to save your progress. Learn more
Email *
Your first name? *
Your last name? *
What is your phone number?  (No hyphens) *
Clear form
Never submit passwords through Google Forms.
This form was created inside of cest la vie. Report Abuse