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Fill out the form below to apply now. All fields are required.
Business Information
Business Name:
Business Address:
City, State and Zip:
Business Phone:
Business Fax:
Website Address:
Describe products or services sold:
Is this a US based business?
Yes
No
Does the owner/authorized signer have a US Social Security #?
Yes
No
Do you currently process credit cards?
Yes
No
What is your average sale in USD?
What is your expected monthly credit card sales volume (in USD)?
How are orders processed?
Must Equal 100%
Card Swiped (retail)
Mail/Telephone order (keyed in)
Ecommerce
Personal Information
Contact Name:
Email:
Phone Number:
Best time to reach you:
Merchant Account Solutions
Which processing solution(s) are you interested in?
Ecommerce / Virtual Terminal
PC Based Processing (via PC Charge)
POS (Point of Sale Terminal)
Other (Please specify)
I am not familiar with all of the options, please call me to discuss
Notes or additional comments
