Please provide the following contact information:

First Name
Last Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail
URL

Language:   English Spanish Asian Indian Arabic Other   

Enter Company DBA (if different than company name):

State of Incorporation/Organization:     

If Sole Proprietorship, Full Legal Name of Owner:

First Name
Last Name
Middle Initial

Business Mailing Address (if same enter “same")

Business Property Leases or Owned:   Leased Owned   

Company Type:   Sole Proprietorship Partnership Limited Liability Corporation  

How much or many years in business?     

Product/Services Sold:

Monthly Credit Card Sales Volume (Gross):     

Average Ticket Amount:     

Current Card Processor:   iPaymex Paymetech First Data/CSI Paypal Other   

Credit Card Processing Method:   In Person By Phone Mail Order Internet Other   

Has owner ever had a merchant account terminated?

Yes No

Has the owner ever declared bankruptcy?

Yes No

Are you in bankruptcy:?

Yes No

Are there tax liens on the business?

Yes No

What time would you like a representative to contact you:

9am     10am     11am     12pm
1pm     2pm       3pm       4pm
5pm

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