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Merchant Information Form
Corn City State Bank
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* Required
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
*
Choose
Yes
No
Existing Processor
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Monthly Sales Volume
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I Am Interested In The following Products
*
Check All That Apply
Credit/Debit Card Processing
Mobile Payments
Ecommerce Solutions
POS Systems
Gift Card/Rewards/Loyalty
Check Processing
Other:
Required
Additional Comments
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Bank Representative Notes
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