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Preliminary Merchant Account Survey
This form will help us determine your merchant account needs. If you're not a merchant, but would like information about our Affiliate reseller program,
click here
Before beginning, please review our
Restrictions
.
Note: All fields marked with a
*
are required. At least one field in each section marked with
*
is required.
Company Information
Company:
*
Address:
*
City, State and Zip:
,
*
Number of other locations:
Years in business:
Check here if this is a seasonal business
Contact Information
Contact Name:
*
Email:
*
Phone:
*
Fax:
Please estimate the following credit card volumes and average ticket amounts:
Number of face-to-face orders per month
*
:
Avg Ticket Amount
*
:
Max Ticket Amount
*
:
$
$
Number of mail/ phone orders per month
*
:
Avg Ticket Amount
*
:
Max Ticket Amount
*
:
$
$
Number of internet (shopping cart) orders per month
*
:
Avg Ticket Amount
*
:
Max Ticket Amount
*
:
$
$
Other payment options:
Visa/Mastercard
American Express
Discover Card
ACH Authorization (pre-authorized checking payments)
Briefly Describe the products/services you offer and your target customer market:
Referral Information
Referred by
*
:
- Please Select -
None
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