Premier America - Chosen Payments Quick Contact Form

If you are a Premier America Credit Union member and would like to take advantage of the many benefits offered through the PA - Chosen Payments partnership please fill out the below information.

Business/DBA Name:

Enter your business or dba name
First Name:

Enter the first name of the owner.
Last Name:

Enter the last name of the owner.
Business Phone:

Enter in the format 800-555-1234.
E-Mail address:

Enter your e-mail address where you like to be contacted.
Web Site:
Enter the business web site.
What industry best describes your business sales environment?:
Mail Order
Check all that apply.