Welcome, Coulee Bank Valued Member

Evolve Payment is Coulee Bank’s trusted community partner for merchant services. Evolve Payment acts as a partner advocate for Coulee Bank’s valued merchants and is excited to welcome you into the Evolve Payment family to help you Bank with Confidence.

Before we kickstart our new relationship, we want to better understand your merchant needs and how we can best serve you. Please complete the following form in as much detail as possible. If applicable, we also request the past three months of current statements for your merchant account.

After you submit the form and we look over your information, a member of our team will reach out to you to schedule an introductory meeting. If you have any questions, don’t hesitate to give us a call, send us an email, or submit our contact form. We look forward to hearing from you!

Coulee Bank Referral Form

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This field is for validation purposes and should be left unchanged.

Name(Required)

Email(Required)

Phone(Required)

Business Name

Business Website

Credit Cards Accepted

Visa

Mastercard

Discover

American Express

Current Bank Customer?

Yes

Business Type

Percentage Card Present

Percentage Phone Order

Percentage Internet Order

PCI Compliant?

Yes

Don't know

Products or Services Transacted on Credit Cards

Payment Equipment

Terminal

PC Software

Payment Gateway

POS System

Additional Information

Three months of current statements

File

Max. file size: 50 MB.

File

Max. file size: 50 MB.

File

Max. file size: 50 MB.

Banker Information

If you are a banker completing on behalf of a client, please provide your information below. Otherwise, please leave this section blank.

Banker Name

First Last

Banker Email

Banker Phone