Merchant Referral Form

 

Thank you for your interest in Global Merchant Services.
Fill out your information as accurate as possible and someone will contact you during the time of day specified.

 


COMPANY CONTACT INFORMATION
Sales Office Name   
Company   
First Name   
Customer Full Name   
Last Name   
Phone   
Referred By   
Mobile/ Cell   
Time Zone   
Home   
Title   
Fax   
Email Address   
Email Address 2   
Website   
Merchant Type   
Federal Tax Number   
Business Type   
Online Application Submission (check box)  
Business Street   
Mailing/Billing Street   
Business Street 2   
Mailing/Billing Street 2   
Business City   
Mailing/Billing City   
Business State   
Mailing/Billing State   
Business Zip Code   
Mailing/Billing Zip Code   
Business Country   
Mailing/Billing Country   
Terminal/ Software Type   
American Express Merchant Number   
Discover Merchant Number   
Notes   
Company Contact Name   
Company Contact Job Title   
Company Contact Phone Number   
Company Contact Email Address   
Product/ Service Specialty   
Products Intrested In   
Average Credit/ Debit Card Ticket   
Highest Credit/Debit Card Ticket   
Projected Monthly Volume   
Annual Revenue   
Affiliate/ Trade Association Name