Merchant Information Form
Green Belt Bank and Trust Savings Bank
Date *
MM
/
DD
/
YYYY
Merchant Name *
Your answer
Merchant Primary Contact *
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Merchant Secondary Contact
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Merchant Street Address
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Merchant City, State Zip
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Merchant Phone Number *
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Merchant Email Address
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Type of Business *
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Currently Accepts Credit Cards *
Existing Processor
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Monthly Sales Volume
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Bank Contact Name
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Bank Contact Email Address
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Branch Name or Location
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Bank Contact Phone Number
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I Am Interested In The following Products *
Check All That Apply
Required
Additional Notes/Comments
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