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Referred By / How Did You Hear About Us? (required)

Company Name (required)

Type of Business (required)

Name (required)

Phone Number (required)

Email (required)

Does Your Business Currently Accept Credit Cards?
---YesNo

What Is Your Monthly Credit Card Sales Volume?
---N/A$100-$10K$20K$30K$30K-$50K$50K-$100K$100K-$200K$200K-$500K$500K-$1MM$1MM-$2MM$2MM-$5MM$5MM-$10MM$10MM+

What Is Your Average Ticket / Sale Amount?
$

Tell Us About Your Terminal's / Equipment
---Not SureI Own My EquipmentI Have Leased EquipmentI Need New Equipment

What Method Do You Use Or Plan To Use To Accept Credit Cards?
---Swipe Face-To-Face TransactionsKey-in Non Face-To-Face TransactionsCombination of Swipe & Key-inWebsite With Shopping CartGateway / Online PortalFront End SoftwareI Have A Proprietary SystemI Am Not Sure

Please Attach Your Last Months Merchant Statements for Accurate Review (3 is always better than 1)

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