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First Name            Business Name
Last Name            Business Address
Email address      City  State    Zip
Phone - -      Fax - -

Business Type     Retail      Restaurant      Salon/Spa      Auto Repair       Internet      Mobile      Other(describe)                                                                                                                                                                                         

Do you have a credit card terminal?   If yes, choose terminal from list (NONE) Omni 3750 vx510 vx570 vx610 GPRS vx610 CDMA vx610 WiFi Hypercom T7P 512K Hypercom T7plus Hypercom T4100 Nurit 2085 Nurit 8000 GPRS Nurit 8320 Nurit 3020 Talento FD100 Telecheck Eclipse

If you already have a credit card terminal, do you own it or lease it?    Own      Lease

Do you have an existing merchant account?  

Indicate which card types you would like to accept or do accept (check all that apply)  Visa      Mastercard     Discover     American Express      Debit      Voyager/Wright Express       EBT

What is your anticipated or actual monthly Visa/Mastercard volume?  PLEASE SELECT A RANGE $0 TO $5,000 $5,000 TO $10,000 $10,000 TO $25,000 $25,000 AND ABOVE

What is your anticipated or actual monthly average transaction size?   PLEASE SELECT A RANGE $0 TO $10.00 $10.00 TO $20.00 $20.00 TO $30.00 $30.00 TO $40.00 $40.00 TO $50.00 $50.00 TO $60.00 $60.00 TO $70.00 $70.00 TO $80.00 $80.00 TO $90.00 $90.00 TO $100.00 $100.00 AND ABOVE

Do you currently use a check verification service?   yes     no

Do you currently use a pin pad for debit transactions?     yes     no

Please indicate the best time to call you to schedule an appointment. 

Please enter any comments or questions that you may have below: