FREE Processing Application
Sales Agent Name *
Your answer
COMPANY INFO
Business Name *
Your answer
Business Location Address *
Your answer
Mailing Address (If different than Business) *
Your answer
Business Phone *
Your answer
Business Email *
Your answer
Business Website *
Your answer
Years in Business *
Your answer
Multiple Locations? *
Type of Business *
Corporate / Legal Name (if Incorporated)
Your answer
Corporate Address (if different than Business)
Your answer
Tax Filing Name (if different than Corporate/Legal Name)
Your answer
Corporate Contact Person's Full Name
Your answer
Corporate Phone
Your answer
Send Retrieval/Charge back Requests to: *
Business Category *
Products/Services Sold *
Your answer
PROCESSING INFO
Currently accept Visa and MasterCard? *
What type of Equipment would you like? *
Monthly Credit Card Sales Volume $
Your answer
Average Transaction $ Amount
Your answer
Current Credit Card Processor Company Name
Your answer
Following sum must = 100%
Card Swipe %
Your answer
Manual Keyed %
Your answer
Phone/Mail Order %
Your answer
Internet %
Your answer
Seasonal Merchant *
If Yes/Seasonal, which months are you CLOSED?
Tax ID / EIN # # - # # # # # # #
Your answer
Primary Contact Name *
Your answer
Primary Contact Title *
Primary Contact % of Ownership (51%+) *
Your answer
Residence Address *
Your answer
Primary Contact Date of Birth *
Your answer
Special Requests/Comments
Your answer
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