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Sales Representative Name *
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COMPANY INFO
Business Name *
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Business Address *
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Business Phone Number *
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Business Email Address *
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Corporate Legal Name
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Corporate Address if different than above
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Type of Business *
Company Website
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Month/Day/Year Business Established *
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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:) *
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Average Transaction $ Amount (Approx:) *
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Highest Potential Trans $ Amount (Approx:) *
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OWNER / PRINCIPAL INFO
Primary Contact Name *
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Primary Contact Title *
Primary Contact % of Ownership (51%+) *
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Primary Contact Date of Birth *
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Tax ID / EIN (or SSN if not Inc.) # # - # # # # # # # *
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Special Requests/Comments
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