Merchant Information Form
Corn City State Bank
Branch Name or Location
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Bank Contact Name
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Date *
MM
/
DD
/
YYYY
Bank Contact Email Address
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Bank Contact Phone Number
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Merchant Name *
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Merchant Primary Contact *
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Merchant Secondary Contact
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Merchant Email Address
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Merchant Phone Number *
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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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I Am Interested In The following Products *
Check All That Apply
Required
Additional Comments
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Bank Representative Notes
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