Merchant Referral Form
Fill out your information as accurate as possible and someone will contact you during the time of day specified.

I am currently interested in:
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hold down the CTRL button
while selecting.
Company and Contact Information
   Affiliate/ Trade Association Name:           Affiliate/ Trade Association Number: Date:
Business Name:
Business Type:
No. of Years in Business:
Business Address 1:
Business Address 2:
City:
State: Zip Code:
Business Phone:
Business Facsimile:
Alternate Number:
Website Address:
Email Address:
Contact Name:
Contact Phone Number:
Contact E-mail:
        Federal Tax #: 
No. of Locations:   
Principal Information
Primary Owner Name:     Title:
Residence Address: 
City:  State: Zip:
   Drivers License No.:    State:
No. Of Years:    Home Phone No.:
Date Of Birth:          S.S.#: 
Secondary Owner Name:     Title:
Residence Address: 
City:  State: Zip:
 Drivers License No.:    State:
No. Of Years:   Home Phone No.:
Date Of Birth:          S.S.#: 

Trade Reference Name: Contact:
Trade Reference Address: Phone #:
Trade Reference Name:  Contact:
Trade Reference Address: Phone #:

Bank Name:
Bank Contact:
Bank Address:
Bank City: Bank State: Zip Code:
Bank Phone: Bank Fax:
Banking Account Name:
Bank Routing Number:    Bank Account Number:
Best Time to Contact You:
Comments: 
Sales Information
Merchant Type:
Products or Services Sold:
Sales Profile: % Swiped
% Manually Keyed
% Mail Order / Internet
Comments: 
Projected Sales Volume

Average Credit Card Ticket:   Credit Card Monthly Volume:

 

Average Check Ticket:     Highest Monthly Check Volume:

  
Merchant Account Information
Do you currently accept credit cards?
If so, who is your current card processor of bank?
Discount Rate %:
 Transaction Fee:
 Monthly Min:
 Statement Fee:
Are you paying a Flat Fee for Check / ATM Debit Cards or a Discount Rate?
Do you currently have check guarantee?
If so, who?
Are you in need of an ATM Machine?
Lease      Purchase      Placement
Would you like to SAVE 15% off every equipment, supply and accessory order?
Did you purchase or lease your equipment?
If leased, how long left?
Comments:
Miscellaneous Information
How did you hear about us?
Affiliate/Trade Association Name:                      Affiliate/ Trade Association Number: Date:
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