Genie CashBox Merchant Membership Form

Activation Fee

Charges on   Activation Fee (One time): $30.00     
permanent   Monthly Fee: $19.95     
activation:   Pre Paid Calling Time: $0.00    $49.95 USD (NO Sales Tax)
Personal Information -  Please complete the form below

Referral Genie No.: 
First Name:  (Required)
Middle Name: 
Last Name:  (Required)
Business Name: 
Genie Gateway Name: 
Web Site: 
Street Address:  (Required)
Apt# / Suite#: 
City:  (Required)
State:  (Required)
Country I reside in:  (Required)
ZIP Code:  (Required)
Cell Phone No.:  (Required)
Cellular Provider:  (Required)
Work Phone No.: 
Home Phone No.: 
Email Address:  (Required)
Confirm Email Address:  (Required)

Your Genie CashBox Merchant temporary passcode will be emailed to this address, please verify that you provided the correct email address, otherwise, you will not be able to access your Genie CashBox Merchant account.

Billing Information

Credit Card No.: (Required)
Use above address
Address: (Required)
ZIP Code: (Required)
Expiration Month: (Required)
Expiration Year: (Required)
Security Code: (Required) What is it?

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