Merchant Information Form
Corn City State Bank
Branch Name or Location
Bank Contact Name
Date *
MM
/
DD
/
YYYY
Bank Contact Email Address
Bank Contact Phone Number
Merchant Name *
Merchant Primary Contact *
Merchant Secondary Contact
Merchant Email Address
Merchant Phone Number *
Type of Business *
Currently Accepts Credit Cards *
Existing Processor
Monthly Sales Volume
I Am Interested In The following Products *
Check All That Apply
Required
Additional Comments
Bank Representative Notes
Submit
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