I am currently interested in: Credit Cards Check/ATM Debit Cards Check Guarantee Cash Advance Program ACH/ Checks by Phone EBT/ Food Stamp Program Virtual Terminal E-Commerce Gift/ Loyalty Cards ATM Machines POS Equipment Register To Win Program Free Statement Analysis Program Lower Rates Affiliate Program Trade Association Program Investor Other

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Company and Contact Information

Business Name:
Business Type:	PLEASE SELECT ONE SOLE PROPRIETORSHIP CORPORATION PARTNERSHIP LIMITED LIABILITY (LLC) NON-PROFIT OTHER
No. of Years in Business:	PLEASE SELECT ONE 1 YEAR 2 YEARS 3 YEARS 4 YEARS 5 TO 10 YEARS 10 TO 20 YEARS 20+ YEARS
Business Address 1:
Business Address 2:
City:
State:	Zip Code:
Business Phone:
Business Facsimile:
Alternate Number:
Website 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:	SELECT ONE 8AM-11AM 11AM-1PM 1PM-5PM
Comments:

Credit Card Sales Information

Merchant Type: SELECT ONE RETAIL RESTAURANT HOME BASED MAIL ORDER ECOMMERCE WIRELESS VIRTUAL TERMINAL TOUCHTONE SERVICE LODGING OTHER Products/ 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? ------- YES NO
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? SELECT ONE FLAT DEBIT FEE DISCOUNT RATE
Did you Purchase or Lease your Credit Card POS Equipment? SELECT ONE PURCHASE LEASE RENT
If leased, how long left?
Do you currently have check guarantee? ------- YES NO
If so, who?
ATM Machine Account Information:
Are you in need of an ATM Machine? ------- YES NO
Lease      Purchase (Cash or Credit Card)     FREE ATM Placement
Surcharge Amount Desired: Number Of Locations:
Foot Traffic Per Hour: How Many Hours Opened Per Day: How Many Days Opened Per Week:
Would you like Parts, Labor and Supplies as a Service Contract for your ATM Machine? ------- YES NO
Comments:

Miscellaneous Information

How did you hear about us?

Sales Office/ Affiliate Name: Reference I.D. Number:   Date:

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