BRG Client Contract

Name*

First Name

Last Name

Email*

Title - Your Role/Position in the Company

Company*

Work Phone

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Referral Code

Please input if applicable

Send Contract For Signature?

Yes No

Tax ID Number

Please provide the EIN (Tax ID) number for this company. Example: 46-1234567

agent_name

agent_email

ZeeStat

validation_code

iso_name

iso_email

Contract Upload

No File Chosen

File uploads may not work on some mobile devices.

uploaded_contract_url

Disclaimer: Claim forms are being delivered and are available online beginning December 1, 2023. Class members need not sign up for a third-party service in order to participate in any monetary relief. No-cost assistance is available from the Class Administrator and Class Counsel during the claims-filing period. Additional information regarding the litigation is available at http://www.paymentcardsettlement.com

Brownstone Representation Application