Merchant Information Form
Fairfax State Savings Bank
* Required
Date
*
MM
/
DD
/
YYYY
Merchant Name
*
Your answer
Merchant Primary Contact
*
Your answer
Merchant Secondary Contact
Your answer
Merchant Street Address
Your answer
Merchant City, State Zip
Your answer
Merchant Phone Number
*
Your answer
Merchant Email Address
Your answer
Type of Business
*
Your answer
Currently Accepts Credit Cards
*
Choose
Yes
No
Unknown
Existing Processor
Your answer
Monthly Sales Volume
Your answer
Bank Contact Name
Your answer
Bank Contact Email Address
Your answer
Branch Name or Location
Your answer
Bank Contact Phone Number
Your answer
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 Notes/Comments
Your answer
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