| Merchant Information |
| Name of Business: | |
| Contact Name: | |
| Title: | |
| Business Address: | |
| City: | |
| State: | |
| Zip Code: | |
| Phone number where you can be contacted: | |
| Best time of day to be contacted: |  PST |
| Email Address: | |
| Business Fax: | |
Have you spoken with an Account Rep
via e-mail or telephone?: | Yes No |
| If Yes, please enter the name of the person: | |
| Type of account: | |
| Does your business currently accept credit cards?: | Yes No |
| If Yes, what is the name of the processor?: | |
| Anticipated monthly Visa/MasterCard sales volume: | |
| Anticipated average per sale amount (in dollars): | |
| Comments: | |
| |
