AMA Solutions: Welcome to AMA

Apply today! Register for processing by providing the following information requested. The applicant must be 18 years of age or older and must be authorized to act on the company's behalf.

A sales representative will contact you within 24 hours to discuss rates and fees, as well as walk you through the rest of the application process. There is no commitment to filling out this form. If you would like to talk to a sales representative, call 800-516-6242 during normal business hours of 8:00 a.m. to 6:00 p.m. CST.

Please supply the following information:
* required field

Practice Name	(This is the name your customers will see on their statements)




First Name

Last Name

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Work Phone

FAX

E-Mail Address*
Best Time To Call





Does your practice currently accept MasterCard & Visa?	Yes No

If "Yes", enter the name of your current processor:

Anticipated monthly MasterCard & Visa volume:	$

Anticipated average charge:	$
Number of physicians in practice:

Any additional comments or concerns?

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