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Agent Form - Invoicing
For any paying clients - after completing the form below, the client will be invoiced.
Agent Name:
Are you signing up a
healthcare employer, Marketplace Advertiser,
or
Other
?
Choose One...
Healthcare Employer
Marketplace Advertiser
Other
Please enter the information below as to be shown on the invoice.
Contact Name:
Company Name:
Email:
Phone number:
Billing Address
# of locations
Pricing
Monthly or Yearly
Choose One...
Monthly
Yearly
Date of first invoice (optional)
Method of payment
Package Details
Additional Notes
Thank you!
Back to Form
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