Merchant Information Form

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Test Bank

Date *

YYYY

Merchant Name *

Merchant Primary Contact *

Merchant Secondary Contact

Merchant Street Address

Merchant City, State Zip

Merchant Phone Number *

Merchant Email Address

Type of Business *

Currently Accepts Cards *

Yes

Monthly Sales Volume

Bank Contact Name

Bank Contact Phone Number

Bank Contact Email Address

Branch Name or Location

I Am Interested In The Following Products *

Notes

Submit

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