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Please fill out all the information below to help us prepare your Merchant Services application. At any time if you need assistance please contact us.
Business Information
Business Name
*
Business Address
*
Business State
*
Select Your State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Business City
*
Business Zipcode
*
Contact Information
Owner/Contact Name
*
Email
*
Phone
*
How did you hear about us?
Service Information
Does your business currently accept credit cards?
Yes
No
Do you currently have credit card equipment at the location?
Yes
No
Not Sure
What is your monthly processing volume?
Under $5,000/month
$5,000 - $10,000/month
$10,000 - $20,000/month
$20,000 - $40,000/month
$40,000 - $100,000/month
Over $100,000/month
What is your average charge amount?
$1.00 - $50.00/transaction
$50.00 - $100.00/transaction
$100.00 - $200.00/transaction
Over $200.00/transaction
How do you accept or plan on accepting credit cards?
Swipe cards at business location in person
Take credit cards online via website
By phone or mail order and manually input data into terminal
Swipe cards thru wireless terminal at customer location
Name
This field is for validation purposes and should be left unchanged.
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