ONLINE APPLICATION:

         * Denotes Required Fields

Owner First & Last Name

 *

Business Name

 *

Physical Business Address

 *

Suite (If Any)

City

 *

State

Select a State Outside US Alabama Alaska Alberta Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Labrador Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Ohio Oklahoma Ontario Oregon Pennsylvania Puerto Rico Quebec Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming  *

Zip Code

 *

(Area Code) Work Phone

 - - *

  (Area Code) Home Phone

 - - *

Best Time to Call

 *

Website Address (If any)

Email Address

 *

How did you hear about us?

 *

Type of Business

Type of Business Retail Store Home-Based Business Mail or Phone Order Business Internet Business/Shopping Cart Flea Market Restaurant Grocery Store Convenience Store Mall or Kiosk Other  *

Length of Ownership

Length of Business Ownership New Business - Less than 30 Days Less than 6 Months 6 Months - 1 Year Less than 2 Years Less than 3 Years 3 or More Years  *

Type of Merchant

Type of Merchant Accepting Credit Cards for the 1st Time Existing Merchant  *

Website?

Does Your Business Have a Website? No, but I want to get a website Yes, I already have a website No, I do not want a website

Equipment/Software Needs

Equipment Software Needs Credit Card Terminal Terminal with Thermal Printer Terminal and PinPad Terminal, PinPad, & Check Reader Wireless Terminal Palm Pilot VII with Card Swiper Computer Software Internet Payment Gateway  *

Average Ticket Size

Average Ticket Size $100 or Less $100 - $500 $500 - $750 $750 - $1000 $1000 or More  *

Monthly Credit Card Volume

Projected Monthly Credit Card Volume Less than $5,000 Volume $5,000 - $10,000 Volume $10,000 - $25,000 Volume $25,000 - $50,000 Volume $50,000 - $100,000 Volume $100,000 & More Volume  *

Comments or Questions?

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