What kind of business do you have?

Retail Store Bar/Restaurant Salon/Spa Mobile

Internet       Lodging           Gas Station

Other

Do you have an existing merchant account?   Yes  No

Indicate which card types you would like to accept.

    Visa   Mastercard American Express  Discover Debit Voyager/WriteXpress

What is your anticipated or actual monthly Visa/Mastercard volume?

            $0 to $1000 $1000 to $5000 $5001 to $10,000 $10,000 to $20,000 greater than $20,000

What is your anticipated or actual average transaction size?

            $0 to $10 $11 to $25 $26 to $50 $50 to $100 $101 to $500 $501 to $1000 ABOVE $1000

Do you need a terminal? Yes No

Do you own or lease your own equipment?  OWN  LEASE

If Yes, please select your terminal type   Hypercom T7P (512K) Hypercom T77 (512K) Hypercom T7plus Hypercom Ice 5700 Nurit 2085 (no pin pad) Nurit 2085+ (w/pin pad) Nurit valuepak 700 Nurit 3010 (wireless) Nurit 8320 Omni 3200 Omni 3730LE Omni 3750 Talento IPP (2UD) Tranz 330 Tranz 380 Tranz 380x2 Verifone VX610 wireless Restaurant POS Aloha Restaurant POS Micros Restaurant POS Squirrel

Do you currently use a check verification service? Yes No

Do you currently use a pin pad for DEBIT transactions? Yes No

Enter your comments in the space provided below:

Tell us how to get in touch with you:

Name
E-mail
Tel
FAX

Please contact me as soon as possible regarding this matter.