Fundraiser Enrollment Form

Fundraiser Enrollment

Please enter your organizational information below:

* Required fields must be completed

Enroller ID:* Enroller Name:

Organizational Information

Full Legal Name that shows on Social Security Card or EIN Form

Contact First Name:*

Contact Last Name:*

Organization Name:

SSN or Tax-ID #: (Required for All U.S. Fundraisers) Tax Exempt:

Phone Number:* Example - 9596768799

https://www.dachealthcare.com/rx/

Personal Site Name:* This NOT your Enroller's Site Name or ID#. Your Site name is for your personal replicated site and can be between up to 20 characters long. Try to use a name that represents you and/or your company name. Please do not use invalid characters like spaces or !@#$%^&*()?.,<>'";:\/{}[].
Enter the unique "user name" in the box above that you want for your Website.
This will be your personal website to use and share. Please write down your website. Example - your "DACHealthcare.com/rx/" website:
If you type "riverchurch" in the box above, your Personal "DACHealthcare.com/rx/" web site will be: https://www.dachealthcare.com/rx/riverchurch
All website address names are subject to approval by DAC

Email Address:*

Please Verify Your Email Address:*

Organization Address

Organization Country:*

Organization Address:*

Organization Suite/Apt:

Organization City:*

Organization State/Province: Other:

Organization Zip:*

Password:* (minimum of 7 characters)

Confirm Password:*

The password you entered above will be used when accessing your backoffice. Please enter your password below twice to make sure it is entered correctly into our system.

By checking this box, I agree that I am authorized to sign on Organization's behalf.

Please Type Your Full Name Below:*