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