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Sales Representative Name *
COMPANY INFO
Business Name *
Business Address *
Business Phone Number *
Business Email Address *
Corporate Legal Name
Corporate Address if different than above
Type of Business *
Company Website
Month/Day/Year Business Established *
Place of Business *
Is Place of Business Leased or Owned
Building Type *
Square Footage of Building *
PROCESSING INFO
Do you currently accept credit cards for payments? *
Monthly Visa/MC/DSC/AMX $ Volume (Approx:) *
Average Transaction $ Amount (Approx:) *
Highest Potential Trans $ Amount (Approx:) *
OWNER / PRINCIPAL INFO
Primary Contact Name *
Primary Contact Title *
Primary Contact % of Ownership (51%+) *
Primary Contact Date of Birth *
Tax ID / EIN (or SSN if not Inc.) # # - # # # # # # # *
Special Requests/Comments
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