New Provider

New Provider

New Revive providers need to complete the following form in order to be set up in the internal systems.

PERSONAL INFORMATION

Address *
Address
City
State/Province
Zip/Postal

PROFESSIONAL INFORMATION

PAYROLL & DIRECT DEPOSIT INFORMATION

If you have created an LLC or corporation which you want to be paid through, please provide its name and federal EIN. The bank account information should also be an account opened in the name of the corporation. If you do not have a corporation you should include your personal bank account information.

PREFERRED PASSWORD

Minimum of 8 Characters
At least 1 letter, number, special character
Can not start with a number or special character

ADDITIONAL INFORMATION

Sending