Please provide the following contact information:

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

What is the best day and time to reach you?

Should we have any questions about your application, please provide the phone number on which you would prefer to receive calls...

Are you currently processing credit card sales?

YES
NO

If yes, please provide the name of your current processing bank;

If so, please select any options that apply to your current processing::

Swiping Cards on a machine
Keying Credit Card Numbers into a machine
Accepting Debit Cards
Shopping Cart Online
Virtual Terminal

If you are not currently accepting credit cards, please let us know approximately how soon you will be needing an active account..

Please select all of the services of which you are interested in receiving information:

Credit Card Processing
Debit Card Processing
Check Conversion / Guarantee
ATM Machine
Custom Loyalty Card / Gift Card Program
Web Site Development / Upgrade
Web Hosting
Virtual Terminal
Shopping Cart

Select any of the following criteria that apply to your type of business. The more information we have regarding your company, the better the package we can create for your needs:

Retail Store Front
Home Based
Web Based
Mail Order

Is your business:

Product Oriented
Service Oriented
Both

If a Product Oriented business, please give us a brief description of the kind / type of products you provide.

If a Service Oriented business, please give us a brief description of the kind of services you provide.

If you currently do not have a website, would you be interested in information about our cost effective website development servcies?

YES
NO

If you currently have a website, are you interested in upgrading and / or enhancing your web presence?

YES
NO

In order to submit your application, the following information is needed. Please be sure to answer each questions with your complete information;

Your Social Security Number is:.

Your EIN # is:

Your date of birth is:

Please provide two trade references. Be sure to include all requested information:

Name
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX

Trade Reference 2

Name
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX

Please provide any additional information you feel is essential to us knowing more about your business and should you have any questions, please feel free to post them here.

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Revised: 06/07/05